• 간호행정학회지
• /
• 제15권2호
• /
• pp.264-274
• /
• 2009

Purpose: This study is to develop job standards in order to propose proper job level of the advanced nurse practitioners and apply the results to the work and enhance the expertism. Method: This study is a methodical study. The validity was examined by using the content validity index(CVI). Result: The pre-items of job standards for advanced health insurance review nurses were established and the final job standards comprising of 12 standards, 46 criteria, 92 indicators, 418 activities were determined after the examination by the advisory group. The validity of the job standards were examined for two times by the seven professionals. The relevance of the modified job standards was examined by the working level employees above the assistant manager position working in the general hospitals and the result was 93.14% relevance. The job standards comprising of 12 standards, 46 criteria, 89 indicator and 409 activities were developed. Conclusions: By the development of the job standards, it is expected to prove that advanced health insurance review nurses are the most suitable professionals for dealing with medical affairs such as management and propriety evaluation of medical expenses while defining the roles of advanced health insurance review nurses.

• 의료법학
• /
• 제15권1호
• /
• pp.185-209
• /
• 2014

While the local health insurance and the employment-based insurance were integrated in July 2000, the insured is divided into employment-based insured and the local insured and the relevant premium has been applied to both groups. The health insurance premium having the feature of social solidarity has to be determined depending on income, that is, the ability to pay in accordance with the principles of social insurance. While employment-based insurance premium has been determined depending on the earned income, the local insurance premium for the local insured has been determined by scoring gross income(evaluated income), property and possession of automobiles. A variety of improvement approaches has been implemented including introduction of the employment-based insurance premium ceiling system (2002) and the change of property scoring system for the local insured (2006). However, the health insurance system which was merged in 2000 has been implemented up to now without significant change even though there were lots of socio-demographic change including increase of income level and the population structure such as low birth and aging. In other words, it is required to implement the premium rating system securing the income-based equity. Nevertheless, it was inevitable to apply the diverse rating standards in the early stage because it was very difficult to verify the income of the self-employed. Although the income verification rate was significantly increased from 23% in 1989 to 44% in 2010, the irrational standards including property, automobiles, living standard and activity rate have been still applied to the local insured because it is difficult to secure the validity of insurance premium rating system and it severely lacks of security. This paper investigated whether the current insurance premium rating system for the local insured imposing the premium on the basis of 'gender' and 'age' complies with the basic human rights secured by the current Constitution of the Republic of Korea with respect to the practical and theoretic irrationality of insurance premium rating system and standards for he local insured. In accordance with the analysis results, this paper proposed the approach to improve the system.

• 대한영양사협회학술지
• /
• 제28권2호
• /
• pp.67-84
• /
• 2022

This study aimed to explore the status of food service outsourcing behavior of long-term care institutions (LTCIs) through a cross-sectional survey using a questionnaire administered between July 16th and August 7th, 2020. The survey respondents were either dietitians or facility managers, who worked at 731 nursing homes, 477 group homes, and 673 day-care centers. Approximately 25.9% of nursing homes, 11.7% of group homes, and 33.1% of day-care centers used a managed-services company to operate their food service units. The main reason for outsourcing food service by nursing homes was related to the staffing of dietitians and cooks, whereas group homes and day-care centers outsourced food services due to factors relating to meal costs and the cooking process. Almost all the LTCIs entered into private contracts for outsourced food services. Only a few food service contracts included the types of meals, nutrition standards such as protein and calories per meal, and the parameter or ratio of food cost. Of the respondents, 84.5% from nursing homes, 87.5% from group homes, and 87.1% from day-care centers agreed that the quality of outsourced food services of the LTCIs should be regulated. Meals are essential for maintaining the health and functional status of LTCI users. As more LTCIs outsource their food services, we suggest the following: (1) Increasing the minimum dietitian staffing standards for LTCIs as per the Welfare of Senior Citizens Act and requiring at least one dietitian for every nursing home, (2) Making it mandatory to use a standard food service contract template when drafting food service contract, and (3) Developing realistic standards for food service operations considering the size and operation type of the LTCIs.

• 한국병원경영학회지
• /
• 제20권2호
• /
• pp.28-38
• /
• 2015

This study was conducted by extending Ajzen's Theory of Planned Behavior(TPB) model in analyzing physician's observance behavior of National Health Insurance review standards. An extended TPB model was proposed by including 'background knowledge'and 'dorganizational commitment'in original model to predict physician's review standards observance behavior. Surveys for data collection were carried out on the physicians who were working in a general hospital, clinics, specialized hospitals, local medical centers and long term care hospitals located in Daegu and Kyoung-Buk province in Korea. Two hundreds twenty copies of questionnaires were distributed and 166 physicians responded. Data were analyzed using a structural equation model. The results show that an affirmative attitude and subjective norms have significant positive effects on physicians' behavior of observing review standards. However, the effect of perceived behavioral control on intention to behavior is not significant. The organizational commitment and background knowledge have a positive effect on the intention of observance of review standards. In conclusion, because physician's observance behaviors are affected by background knowledge and organizational commitment as well as attitudes, subjective norms, hospital managements should establish a communication system to share information on the review standards among physicians and provide appropriate measures to increase physician's organizational commitment.

• 한국콘텐츠학회논문지
• /
• 제11권4호
• /
• pp.263-272
• /
• 2011

본 연구는 국내외 문헌고찰을 통하여 건강보험과 산재보험, 자동차보험을 중심으로 선진국의 국민의료비 관리제도를 살펴보고, 우리나라 국민의료비 관리제도의 문제점을 파악하여 올바른 국민의료비 관리방안을 제안하는데 목적이 있다. 분석결과 첫째, 선진국의 경우 국민의료비를 단일기관에서 통합해 운영하면서, 동일한 수가와 급여기준을 가지고 운영하고 있었다. 즉, 의료비 발생원인에 관계없이 동일한 기관에서 동일한 기준으로 통합관리하고 있었다. 둘째, 우리나라의 경우 국민의료비를 보험제도별로 다른 기관에서 분리운영하면서, 서로 다른 의료비 심사·평가, 수가를 적용하고 있었다. 이로 인해 동일증상과 상병임에도 불구하고 관리주체에 따라 의료이용량의 차이가 매우 컸다. 이러한 문제를 근본적으로 해결하기 위해서는 의료비발생의 원인이 무엇이든지 하나의 기관에서 동일한 수가체계와 기준에 근거해 통합관리해야 한다.

• 대한예방한의학회지
• /
• 제21권3호
• /
• pp.29-42
• /
• 2017

Background : Efforts towards increasing insurance coverage for traditional Korean medicine (TKM) are being continued. However, various difficulties are faced in generating evidence for TKM due to limited financial support and the low quality of research methodology. Objectives : The objectives of this study were to review the Swiss evaluation program for complementary and alternative medicine (CAM) and assess the expansion in public health insurance coverage of complementary medicine as approved by referendum in Switzerland. Methods : The regulations of CAM in the European Union were assessed. Research articles, reports, government publications and websites which deal with the 'Programm Evaluation $Komplement{\ddot{a}}rmedizin$ (PEK)' and the referendum in Switzerland were searched for and analyzed. Results : The PEK was conducted from 1998 to 2005. The PEK evaluated the efficacy, utilization and cost-effectiveness of anthroposophical medicine, homeopathy, neural therapy, phytotherapy and traditional Chinese medicine. However, clear conclusions could not be drawn from the evaluation according to the PEK Report. Later, a referendum was implemented in which 5 therapies would be added to the Switzerland Constitution with the support of the public. The coverage of CAM was approved by Swiss a plebiscite with an approval rate of 67.0%. Conclusions : The reason for the successful referendum is suggested to be public support and the solidarity with CAM experts and politicians. It may be surmised that recognition of the political efforts and scientific aspects required to expand insurance coverage of TKM, and towards obtaining public support, is necessary.

• 한국임상보건과학회지
• /
• 제1권3호
• /
• pp.1-9
• /
• 2013

Purpose. This research is implemented to identify the status of educations about the pricing standard, status of the cognition of the pricing standard, and the solutions to the questions on the pricing standard of the oral health professionals. it will provide the easier accessibility to the annual changes in Dental Health Insurance Standards to the oral health professionals. Methods. The research subjects are the total 204 oral health professionals in limited area, and it was analyzed with structured questionnaires. The collected data is analyzed by IBM SPSS ver. 19.0, a statistical program (IBM Co., Armonk, NY, USA) for the frequency and percentage, and ANOVA. The result is as following Results. The awareness of dental health insurance standard was statistically significant differences by age (p<0.01), career (p<0.001), the prime task (p<0.01), and dental insurance claimants (p<0.05). The awareness of the standard was statistically significant differences by educational training within last 6 months (p<0.05), the cognition of the standard (p<0.001), and solutions for the questions (p<0.05). Conclusions. As the results of the research, it is necessary to develop the educational program under condition of age, career, main task, and better understanding in Dental Health Insurance Standard for oral health professional.

• 한국병원경영학회지
• /
• 제2권1호
• /
• pp.1-21
• /
• 1997

In order to analyze the shifts in the volume and profits of Computed Tomography(CT) and Magnetic Resonance Imaging(MRI) utilization for a year before and after the implementation of insurance coverage for CT, this study has been undertaken examining CT and MRI cost data from 'Y' University Hospital situated in Seoul, Korea. Following are the results of this study: 1. The medical insurance payment for CT, implemented on January 1, 1996, increased CT utilization from January 1996 to April 1996 due to low insurance premiums: however, from May 1996 the number of CT cases significantly decreased as a result of strengthened medical cost reviews and the new 'Detailed standards for approval of CT' announced near the end of April 1996 by the insurer. 2. Since the implementation of insurance coverage for CT, CT fee reduction rates for reimbursements by the insurer to the hospital were 50% and 40% for January and February, respectively, and 31% and 15% for March and April. A significant point in the lowering of the reduction rate was reached in May at 11%; furthermore, since June the reduction rate fell below the average reduction rate for reimbursements for all procedures. If the 'Detailed standards for approval of CT' had been announced before the implementation of insurance coverage for CT, CT utilization would not have been so high due to the need to meet those 'standards'. In addition, loss of hospital profits resulting from the reduction for reimbursements would not have occurred. 3. The shifts in MRI utilization showed that there was no particular change with the beginning of insurance coverage for CT, and the introduction of the 'Detailed standards for approval of CT' made MRI utilization increase because MRI is free of restrictions imposed by the insurer. 4. The relationship between CT utilization and MRI utilization showed that they were supplementary to each other before insurance coverage for CT, but that CT was substituted for MRI because of strengthened medical cost reviews after t~e beginning of insurance coverage for CT. 5. The shifts in volume by patient characteristics showed that the number of inappropriate case patients, according to the insurer's "Standards for approval", decreased more than the number of appropriate case patients after the introduction of insurance coverage for CT. Therefore, the health insurance fee schemes for CT have influenced patient care. 6. The shifts in profits from CT utilization showed a net profit decrease of 31.6%. In order to match the pre-coverage profit level, 5,471 more cases would need to be seen and productivity would need to be increased by 32.7%. This profit decrease resulted from a decrease of CT utilization and low reimbursements. With insurance coverage, net profits from CT were 24.4%, and a margin of safety ratio was 39.6%. Because of the net profits and margin of safety ratio, CT utilization fees for insured appropriate cases could not be considered inappropriate. 7. The shifts in profits from MRI utilization before and after the introduction of CT coverage showed that in order to match pre-CT coverage profit levels, 2,011 more cases would need to be seen and productivity would need to be increased by 9.2%. The reasons for needing to increase the number of cases and productivity result from cost burdens created by adding new MRI units. But with CT coverage already begun, MRI utilization increased. Combined with a minor increase in the MRI fee schedule, MRI utilization showed a net profit increase of 18.5%. Net profits of 62.8% and a 'margin of safety ratio' of 43.1% for MRI utilization showed that the hospital relied on this non-covered procedure for profits. 8. The shifts in profits from CT and MRI utilization showed the net profits from CT decreased by 2.33billion Won while the net profits from MRI increased by 815.7million Won. Overall, these two together showed a net profit decrease of 1.51billion Won. The shifts in utilization showed a functional substitutionary relationship, but the shifts in profits did not show a substitutionary relationship. From these results, We can conclude that if insurance is to be expanded to include previously uncovered procedures using expensive medical equipment, detailed standards should be prepared in advance. The decrease in profits from the shifts in coverage and changes in fees is a difficult burden that should be shared, not carried by the hospital alone. Also, a new or improved fee schedule system should include revised standards between items listed and the appropriateness of the fee schedule should constantly be ensured. This study focused on one university hospital in Seoul and is therefore limited in general applicability. But it is valuable for considering current issues and problems, such as the influence of CT coverage on hospital management. Future studies will hopefully expand the scope of the issues considered here.

• 한국보건간호학회지
• /
• 제24권2호
• /
• pp.285-301
• /
• 2010

Purpose: The study was aimed at qualitatively enhancing and promoting a home visiting nursing program established in Korea on July 1, 2008, as part of the Long-Term Care Insurance for the Elderly program. Methods: Structural, procedural and consequential aspects of home visiting nursing care wereclassified on the horizontal axis by applying the standard notions for the evaluation of medical care (Donabedian, 1998). At the same time, the home visiting nursing care service support system and the service provision system weredivided on the vertical axis with reference to the accreditation standards for home visiting nursing care organizations suggested by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO, 2008). The data were collected from June 4, 2008 to October 27, 2008, and were analyzed using SPSS ver. 15.0. Results: Twenty-two (proposed) standards, centered on the standard elements under the conceptual framework of the study, were developed, and comprised structural aspects (n=10), procedural aspects (n=6) and consequential aspects (n=6). Those criteria and indicators underwent two content validity surveys among groups of home visiting nursing care research and training experts. The research produced 22 proposed standards, 50 proposed criteria and 166 proposed indicators. Conclusion: The home visiting nursing care standards developed pursuant to the Long-Term Care Insurance for the Elderly Act and the applicability of these standards need to be verified by home visiting nurses. These proposed standards should prove useful in developing an assessment tool to encourage the qualitative enhancement of visiting nursing care in Korea.

• 한국방사선학회논문지
• /
• 제14권6호
• /
• pp.801-810
• /
• 2020

본 연구에서는 PET 검사의 건강보험 적용 및 급여기준 변경 현황을 살펴보고, 지난 10년간 건강보험 이용량을 분석하였다. PET 검사가 건강보험으로 적용된 것은 2006년으로 ¹⁸F-FDG가 최초로 건강보험으로 적용된 이후 여러 가지 방사성동위원소를 이용한 PET 검사가 건강보험으로 적용되고 있다. 2019년 기준 PET 검사 수는 198,651건, 진료금액은 약 883억원이며, 일반적 특성에 따른 검사 수는 남성이 여성보다 많았고, 연령별로는 60대에서 검사수가 가장 많았다. 외래 검사수가 입원 검사수 보다 많았고, 상급종합병원 검사수가 68.2%로 종합병원, 병원보다 월등히 많았다. 검사부위는 토르소 검사가 86.6%로 가장 많았으며, 방사성동위원소는 ¹⁸F-FDG를 이용한 검사수가 93.6%로 가장 많았다. 10년간 건강보험 이용량 변화로는 2010년 부터 2014년까지 꾸준히 증가하였으나 2014년 정부의 건강보험 적용기준 변경에 따라 무증상 장기추적 검사의 인정이 삭제되면서 이용량이 이후 급격히 감소하였다. 정부의 건강보험 적용기준 변경이 건강보험 이용량 변화에 큰 영향을 주는 만큼 향후 지속적인 모니터링이 필요할 것이다.