Review Article

주요국의 의약품 급여관리를 위한 수평탐색 현황 비교

With the recent development of innovative medical technology, the market entry of high-priced drugs, such as Kymriah, Zolgensma, and Luxturna injections, is increasing. Accordingly, there is a growing need to effectively manage benefits by reviewing the characteristics of drugs, significant adverse reactions, and treatment effects in advance through horizon scanning. This study conducts a literature review of the status and methodology of domestic and foreign horizon scanning and proposes horizon scanning methods for pharmaceutical benefits management. The review results indicate that horizon scanning in Europe had different operational plans, such as the scope and duration of the search by country. However, the implementation typically aimed to reflect horizon scanning in policy decisions, such as determining benefits directions or establishing a regulatory agency management plan. Meanwhile, the results of horizon scanning in the United States and Korea were provided as reference materials to major stakeholders rather than directly reflecting them in the policy. Although listing high-priced drugs with uncertain long-term treatment effects and financial impact is expected to increase, periodic horizon scanning activities for pharmaceutical benefits management have not been conducted in Korea. Therefore, as a horizon scanning procedure for pharmaceutical benefits management, this study proposes the following four steps, namely, (step 1) define target indications and drug efficacy groups; (step 2) establish the purpose of horizon scanning; (step 3) review the extant literature; (step 4) summarize and discuss the results; (step 5) deliberate potential decision-making.

HIRA Research 2024; 4(1): 20-33

Review Article

의료기기 통합정보를 활용한 건강보험심사평가원과 식품의약품안전처의 정보 연계 방안

With the expansion of the medical device market, the efficient distribution and post-management of therapeutic materials have become increasingly important. Because of the transfer of the management system to the Ministry of Health and Welfare, inefficiencies arise from unlinked data between the Ministry of Food and Drug Safety (MFDS) and the Health Insurance Review & Assessment Service (HIRA). To solve this problem, we analyzed the phenomena that occur when linking information from the Therapeutic Materials Guide Map with information from the MFDS. Furthermore, we analyzed the roadmap for the “EDI (electronic data interchange) Standard Code Model Name Transition” and the Medical Device Supply Reporting System to propose improvement methods to enhance the reliability of data provided by the Integrated Medical Device Information System and integrate unlinked data of the MFDS and HIRA. When reporting medical device supply, errors can occur in the EDI codes because the EDI code data are registered directly by the manufacturers. The HIRA must be able to manage and verify the EDI code data entered by the manufacturers in the Integrated Medical Device Information System. The usage and linkage of UDI (unique device identifier) and EDI codes hold promise, particularly when using the Medical Device Supply Reporting System. Integrating medical device information from the MFDS and HIRA will enhance the efficiency of medical device management and contribute to the effective operation of health insurance systems. The Medical Device Supply Reporting System, which is unique to Korea, should be actively used for system improvements to strengthen the competitiveness of the domestic medical device industry and contribute to public health protection.

HIRA Research 2024; 4(1): 34-48

Review Article

장애인 방문재활제도 도입 방안 고찰: 국내외 사례를 중심으로

Disabled patients often have poor health conditions and a high medical cost burden. According to a survey, the second-largest health care service that should be strengthened for the disabled was home-based rehabilitation. Accordingly, laws were revised and a pilot project was implemented, but the results were still insufficient. This study reviewed home-based rehabilitation in Korea and foreign countries. Data, such as laws, information on related organizations, and research reports, were collected for each country. Korea provided home-based rehabilitation for convalescent and chronic patients through National Health Insurance. Home-based rehabilitation is provided by a multidisciplinary team including doctors, nurses, and therapists, and doctors are qualified as specialized in rehabilitation medicine. In foreign countries, such as Japan, the United States, Australia, and Singapore, doctors, nurses, therapists, and other specialists belonging to primary institutions provide comprehensive home-based health and medical services including rehabilitation. There is no requirement for physician specialization, and in some countries, a doctors’ prescription is not necessary for home-based rehabilitation. Medical cost varies depending on the service content and healthcare payment system of each country. In Singapore, Home Environment Review service is part of Home Therapy, and the therapist assesses, improves, and links resources to support the home risk factors. It is difficult to apply home-based rehabilitation to all disabilities due to differences in conditions and required treatment. This assessment requires careful consideration from multiple perspectives.

HIRA Research 2024; 4(1): 49-62

Original Article

병원 연간 환자 수를 추정하는 인공지능 학습방법의 성능평가

Background: Multiple artificial intelligence (AI) methods are being applied to estimate health care sectors’ capacities. This study evaluated AI techniques’ predictive performance for determining the annual number of patients in hospitals.
Methods: The units of analysis were individual hospitals. This study used a dataset consisting data from 708 hospitals in 2021. Training and test datasets were divided by a ratio of 8:2. The two dependent variables were total length of inpatient stay (TLOS) and total number of outpatient visits (TNOV). Four machine learning techniques were used: linear regressor (LR), random forest (RF), gradient boosting model, and extreme gradient boost. Model performance was evaluated with coefficient of determination (R2) in addition to mean squared error (MSE), mean absolute error (MAE), and root mean square error (RMSE). The study used Python version 3.7.0.
Results: The best-fit model for predicting TLOS (R2=0.730) and TNOV (R2=0.707) was RF and LR, respectively. Both RF and LR also had the lowest MSE, MAE, and RMSE scores for inpatient and outpatient predictions. The most remarkable factor associated with a good prediction of the inpatient sector was number of beds followed by number of nurses. In contrast, the best predictive factor for the outpatient sector was number of doctors followed by number of local households.
Conclusion: This study confirmed that AI methods are successful at predicting hospitals’ annual patient loads. Among them, the RF and LR models showed the best performance in predicting both inpatient and outpatient annual loads, respectively. This study proposes that the AI tools utilized in this study can accurately predict future medical demand.

HIRA Research 2024; 4(1): 73-86

Original Article

건강보험청구자료(2016-2022년)를 활용한 일개 지역 진료의뢰 및 회송 청구현황

Background: In Korea, the roles of medical institutions are not differentiated. As a result, the proportion of outpatient medical expenses at clinics mainly targeting outpatients decreased by about 9%p from 69.0% in 2006 to 60.3% in 2021, while the proportion of outpatient expenses at tertiary hospitals increased by about 4.5%p from 11.5% in 2006 to 16.0% in 2021. The government has operated a pilot referral and transfer project to improve the medical delivery system. This study aimed to analyze the current status of a pilot project for a referral and transfer system within the community.
Methods: This study used data from the National Health Insurance Claims from 2016 to 2022, which included patient information (sex, age, disability, income, and Charlson comorbidity index), medical information (type of medical institution and main diagnosis category), and type of referral and transfer.
Results: The number of referral and transfer claims in the region has continued to increase, reaching a total of 296,824. Patients referred for treatment consisted of those aged over 60 years (48.1%), those able to sufficiently cover their medical expenses (42.5%), those without disabilities (90.9%), or those with low disease severity (72.5%). Tertiary and general hospitals had high rates of patients with severe diseases, such as neoplasms (17.2%) or circulatory system diseases (12.6%), returning to local hospitals. Despite the moderate number of referral claims, they have continued to increase yearly, and the methods used to obtain patients’ medical information are also changing.
Conclusion: Although transfers to tertiary general hospitals continued to be active, a large gap exists among medical institutions due to the poorly established medical delivery system. Thus, to increase the efficiency of the medical delivery system, wide implementation of various methods is needed to promote referral and transfer.

HIRA Research 2024; 4(1): 87-100


개정된 OECD의 보건의료체계 성과평가 프레임워크: 회복 탄력적이고 사람 중심적인 성과평가를 향하여

In January 2024, the OECD (Organisation for Economic Co-operation and Development) published a revised Health System Performance Assessment (HSPA) framework at the Health Ministers’ meeting in order to identify and address current and anticipated challenges in the health system. The purpose of the revised framework is to integrate key dimensions such as resilience and people-centeredness into HSPA framework. The core of the revised framework is to place health needs and preferences of people at the center of the framework and structure the four cross-cutting and circulating dimensions of health system performance: efficiency, equity, sustainability, and resilience. In order to implement the framework, the various concepts of the framework must be broken down into more specific and measurable elements and then filled with indicators. Since the components of the revised framework are based on the existing frameworks, the OECD has already developed many indicators. However, revisions to the framework provide opportunities to introduce new indicators and enhance the quality of existing ones. The OECD clarified that the revised HSPA framework is not intended to replace national-level HSPA frameworks but to enable international benchmarking and mutual learning. Recently, Korea announced the 2nd National Health Insurance Plan (2024–2028). Hence, Korea also needs to elevate policy interest in improving the quality of health system and benchmark the revised OECD framework to discuss the establishment of an HSPA framework at the national level.

HIRA Research 2024; 4(1): 113-123

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