National Health Insurance Claim of Pediatric Appendectomy With Mandatory Diagnosis-Related Group Payment System in Korea

IF 1.8 3区 医学 Q2 SURGERY Journal of Surgical Research Pub Date : 2024-10-24 DOI:10.1016/j.jss.2024.09.076
Yun Jung Lee BS , Sanghoon Lee MD, PhD
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Abstract

Introduction

Enforcement of diagnosis-related group system for appendectomy under the National Health Insurance Service has gradually widened and since July 2013 it has been enforced in all medical institutions in Korea. We have analyzed Health Insurance Review & Assessment Service data to observe changes in claim patterns of pediatric appendectomy during this period.

Methods

All claims data for appendectomy of patients younger than 18 y from 2011 to 2015 were collected. We analyzed the following factors of all cases: age, gender, length of hospital stay, medical cost, method of insurance claim and region.

Results

A total of 112,143 claims were made for appendectomy during the study period. In that, 66,510 (59.3%) were boys and 45,633 (40.7%) were girls. Median length of stay was 5 d and median sum of reimbursement of each claim was 2,198,630 won. Annual number of claims for appendectomy showed a steady decline from 24,888 in 2011 to 19,070 in 2015. Median sum of reimbursement of each claim was 1,862,615, 1,975,500, 2,233,360, 2,376,700, and 2,468,000 won, respectively from 2011 to 2015. Reimbursement for complicated appendectomy increased from 4400 out of 24,888 cases (17.7%) in 2011 to 3865 out of 19,070 cases (20.3%) in 2015. Overall medical cost of all reimbursement for pediatric appendectomy increased from 46,113,202,580 to 47,572,253,300 won.

Conclusions

Following the universal enforcement of the diagnosis-related group claim system for appendectomy by the National Health Insurance Service, we observed an increase in the median sum of reimbursement per claim and a rise in the rate of claims for complicated appendectomies. These changes were associated with an overall increase in national medical costs.
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韩国小儿阑尾切除术的国民健康保险理赔与强制诊断相关团体支付系统。
简介自 2013 年 7 月起,韩国所有医疗机构都开始实施阑尾切除术的诊断相关组制度。我们分析了健康保险审查和评估服务数据,以观察在此期间小儿阑尾切除术索赔模式的变化:方法:我们收集了 2011 年至 2015 年所有 18 岁以下阑尾切除术的索赔数据。我们分析了所有病例的以下因素:年龄、性别、住院时间、医疗费用、保险理赔方式和地区:研究期间,共有 112,143 例阑尾切除术索赔。其中,66,510 人(59.3%)为男孩,45,633 人(40.7%)为女孩。住院时间中位数为 5 天,每份报销申请的报销金额中位数为 2,198,630 韩元。阑尾切除术的年报销次数从 2011 年的 24 888 例稳步下降至 2015 年的 19 070 例。从 2011 年到 2015 年,每项报销金额的中位数分别为 186.2615 万韩元、197.55 万韩元、223.336 万韩元、237.67 万韩元和 246.8 万韩元。复杂阑尾切除术的报销比例从 2011 年的 24888 例中的 4400 例(17.7%)增至 2015 年的 19070 例中的 3865 例(20.3%)。小儿阑尾切除术所有报销的总体医疗费用从 4611320.58 万韩元增加到 475722.53 万韩元:在国民健康保险服务机构普遍实施阑尾切除术诊断相关分组报销制度后,我们观察到每次报销的中位数增加,复杂阑尾切除术的报销率上升。这些变化与全国医疗费用的总体增长有关。
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来源期刊
CiteScore
3.90
自引率
4.50%
发文量
627
审稿时长
138 days
期刊介绍: The Journal of Surgical Research: Clinical and Laboratory Investigation publishes original articles concerned with clinical and laboratory investigations relevant to surgical practice and teaching. The journal emphasizes reports of clinical investigations or fundamental research bearing directly on surgical management that will be of general interest to a broad range of surgeons and surgical researchers. The articles presented need not have been the products of surgeons or of surgical laboratories. The Journal of Surgical Research also features review articles and special articles relating to educational, research, or social issues of interest to the academic surgical community.
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