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Original Articles
- Impacts of DRG Payment System on Behavior of Medical Insurance Claimants.
- Beom Man Ha, Gilwon Kang, Hyoung Keun Park, Chang Yup Kim, Yong Ik Kim
- Korean J Prev Med. 2000;33(4):393-401.
- 3,013 View
- 32 Download
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Abstract
PDF - OBJECTIVES
To evaluate the impacts of the DRG payment system on the behavior of medical insurance claimants. Specifically, we evaluated the case-mix index, the numbers of diagnosis and procedure codes utilized, and the corresponding rate of diagnosis codes before, during and after implementation of the DRG payment system. METHODS: In order to evaluate the case-mix index, the number of diagnosis and procedure codes utilized, we used medical insurance claim data from all medical facilities that participated in the DRG-based Prospective Payment Demonstration Program. This medical insurance claim data consisted of both pre-demonstration program data (fee-for-service, from November, 1998 to January, 1999) and post-demonstration program data (DRG-based Prospective Payment, from February, 1999 to April, 1999). And in order to evaluate the corresponding rate of diagnosis codes utilized, we reviewed 820 medical records from 20 medical institutes that were selected by random sampling methods. RESULTS: The case-mix index rate decreased after the DRG-based Prospective Payment Demonstration Program was introduced. The average numbers of different claim diagnosis codes used decreased (new DRGs from 2.22 to 1.24, and previous DRGs from 1.69 to 1.21), as did the average number of claim procedure codes used (new DRGs from 3.02 to 2.16, and previous DRGs from 2.97 to 2.43). With respect to the time of participation in the program, the change in number of claim procedure codes was significant, but the change in number of claim diagnosis codes was not. The corresponding rate of claim diagnosis codes increased (from 57.9% to 82.6%), as did the exclusion rate of claim diagnosis codes (from 16.5% to 25.1%). CONCLUSIONS: After the implementation of the DRG payment system, the corresponding rate of insurance claim codes and the corresponding exclusion rate of claim diagnosis codes both increased, because the inducement system for entering the codes for claim review was changed. -
Summary
- The Accuracy of ICD codes for Cerebrovascular Diseases in Medical Insurance Claims.
- Jong Ku Park, Ki Soon Kim, Chun Bae Kim, Tae Yong Lee, Kang Sook Lee, Duk Hee Lee, Sunhee Lee, Sun Ha Jee, Il Suh, Kwang Wook Koh, So Yeon Ryu, Kee Ho Park, Woonje Park, Seungjun Wang, Hwasoon Lee, Yoomi Chae, Hyensook Hong, Jin Sook Suh
- Korean J Prev Med. 2000;33(1):76-82.
- 4,099 View
- 152 Download
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Abstract
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- OBJECTIVES
We attempted to assess the accuracy of ICD codes for cerebrovascular diseases in medical insurance claims (ICMIC) and to investigate the reasons for error. This study was designed as a preliminary study to establish a nationwide surveillance system. METHODS: A total of 626 patients with medical insurance claims who indicated a diagnosis of cerebrovascular diseases during the period from 1993 to 1997 was selected from the Korea Medical Insurance Corporation cohort (KMIC cohort: 115,600 persons). The KMIC cohort was 10% of those insured who had taken health examinations in 1990 and 1992 consecutively. The registered medical record administrators were trained in the survey technique and gathered data from March to May 1999. The definition of cerebrovascular diseases in this study included cases which met one of two criteria (Minnesota, WHO) or 'definite stroke' in CT/MRI finding. We questioned the medical record administrators to explain the error if the final diagnoses were not coded as stroke. RESULTS: The accuracy rate of the ICMIC was 83.0% (425 cases). Medical records were not available for 8.2% (51 cases) due to the closing of hospitals, the absence of a computer system or omission of medical record, etc. Sixty-three cases (10.0%) were classified as impossible to interpret due to insufficient records in 'major clinical symptoms' or 'neurological deficits'. The most common reason was 'to meet review criteria of medical insurance benefits (52.9%)'. The department where errors in the ICMIC occurred most frequently was the department for medical insurance claims in the hospital. CONCLUSION: The accuracy rate of the ICMIC was 83.0%. -
Summary
- Industry of Employment and Spontaneous Abortion of Female Workers.
- Joung Soon Park, Myung Chae Na, Do Myung Paek, Ok Ryun Moon
- Korean J Prev Med. 1994;27(2):242-257.
- 2,744 View
- 26 Download
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Abstract
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- In Korea, female workforce has reached more than 40% of total working population but the effects of work on spontaneous abortion are yet to be examined. This study was conducted to investigate the occupational effects on spontaneous abortion. Medical insurance claim data were used to examine the effects of the employment status and industry of employment on spontaneous abortion The study population was composed of females, aged 15~44, who were the beneficiary of medical insurance in the month of June, 1993. The working females covered by medical insurance for industrial workers, hand the highest age-adjusted Spontaneous Abortion rate(SAB rate=claim frequency of spontaneous abortion/claim frequency of complication of pregnancy, childbirth and the puerperium), 6.65% whereas female dependants of medical insurance for industrial workers had the lowest age-adjusted SAB rate, 4.54%. Among industrial workers, the workers in manufacturing industry had the highest age-adjusted Spontaneous Abortion ratio(SAB ratio=claim frequency of spontaneous abortion/claim frequency of completely normal delivery), 43.2/100 whereas those in financing and service industry had age-adjusted SAB ratio, 16.2/100 and 20.5/100, respectively. The results of the study suggest the adverse effect of manufacturing industry on reproduction. Work environment such as chemical exposures, overwork, awkward posture, and job stress should be further studied for their effects on reproductive functions of female.
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