Editorial 2022-05-31

HIRA Research 창간호가 발간된 지 어느 덧 1년이 되었습니다.
그 간 발표된 두 권의 학술지에는 새로운 도전에 원동력이 될 만큼 열정과 관심 속에서 총 25편의 논문이 게재되었습니다. 창간호에는 보건의료 발전 방향과 감염병 대유행의 대응 방안을 다뤘고, 더불어 건강보험심사평가원이 앞으로 이끌어가야 할 역할 등에 대해 거침없는 목소리가 담겨졌었습니다. 이어서 두 번째는 정부에 바라는 보건의료정책과 보건의료의 질 향상, 그리고 빅데이터 활용 전략 등 더욱 다양한 학술적 논의의 기회가 펼쳐지기도 했었습니다.
창간 초기, 우리 학술지는 다양한 분야의 시각을 통해 의견을 나누고 토론할 수 있는 학술적 공론의 장이 되기를 다짐했었습니다. 그리고 다양한 형태의 논문을 수렴하겠다고 했습니다. 1년을 맞이하면서 HIRA Research가 건강보험 분야에 전문성 있는 학술지로 초석을 다질 수 있었던 것은 짧은 시간이지만 많은 연구자, 전문가들께서 일궈주신 값진 토양이 있었기 때문입니다.
보건의료 환경의 정점을 찍을 만큼 세상을 흔들어 놓은 코로나19 확산은 보건의료계가 디지털 헬스케어, 인공지능, 빅데이터 등 디지털 기술이라는 미래 도약에 주목할 수 있도록 하였습니다. 반면에 이를 가속화하기 위한 찬반 논쟁이 이어져오는 가운데 이번 세 번째 학술지에는 디지털 기술의 보상체계에 대한 국외 사례와 정책 제언 등을 다뤘습니다. 한편 코로나19 실제 터전인 생활치료센터와 선별진료소의 운영에 대한 현장의 소리가 생생하게 입수되었습니다. 더불어 환자와 일반인을 대상으로 한 경험과 지식 등을 조사한 탐색적 연구가 전개되었고, 의료기관과 간호 인력 등 보건의료 자원 관리에 고려해야 할 요인들을 분석한 연구들을 담았습니다.
2022년, 새 정부 출범으로 보건의료계는 전략과 도전의 해가 될 것입니다. 건강한 보건의료가 소통으로 수립해 나갈 수 있도록 새 정부에 바라는 보건의료 정책 의견을 모아주시기 바랍니다. HIRA Research의 문은 언제나 열려있습니다. 감사합니다.

HIRA Research 2022; 2(1): 7-7

Review Article 2022-05-31

디지털 기술의 건강보험 보장방법에 대한 고찰 : 5개 국가 중심

With the development of various digital technologies such as artificial intelligence, internet of things, mobile health programs, wearable devices, and medical three-dimensional printing technology, healthcare paradigms are changing toward increasing the quality of care and user demand. The value of specificity, individuality, and individual choice of digital technology affects all organizations, management, payment and approach for health maintenance. We reviewed the regulatory guidelines and current status of the United States, Japan, United Kingdom, Germany, and Republic of Korea in order to understand the current status of health insurance coverage of digital technology and to respond to various medical needs. Each of the five countries has applied various reimbursement approaches for digital technology according to the healthcare insurance system. For example, when digital technology applied with artificial intelligence-based software used is judged to improve the clinical outcome of a stroke patient, an additional fee is given to the diagnosis-related group costs in the United States, and costs on therapeutic mobile applications were compensated in Germany. Although the current state of introducing digital technology into health insurance varies by country, they were considering applying it as health insurance for medical services to improve medical quality and patient satisfaction. In conclusion, the suggestions about the digital technology into our national health insurance system in the future are as follows. First, it is necessary to present an appropriate protocol as a guideline for use in actual medical fields. Second, a reasonable compensation method should be considered by creating a new fee schedule that considers the cost of digital technology. Third, the scope, function, purpose, as well as type of technology, is considered. In addition, compensation methods should be reviewed based on a rational evaluation basis, but decisions should be made in consideration of both the positive and negative effects of digital technology.

HIRA Research 2022; 2(1): 9-23

Review Article 2022-05-31

독일의 디지털치료기기 보상체계와 시사점

Digital therapeutics have attracted worldwide attention due to the current situation aggravated by the coronavirus disease 2019 pandemic. Digital therapeutics refers to a type of “software as a medical device” that provides evidence-based therapeutic intervention to patients for the prevention, control, or treatment of medical disabilities or diseases. The scale of the related industry is gradually expanding, both at home and abroad, and related products are in active development. Therefore, this study reviews the case of Germany, the only country that operates a standardized compensation process for digital therapeutics in its Statutory Health Insurance, to provide the latest information on digital therapeutics in Germany and derive its implications. In Germany, digital therapeutics are registered and managed under BfArM (Bundesinstitut für Arzneimittel und Medizinprodukte) based laws such as DVG (Digitale-Versorgung-Gesetz) and Digitale Gesundheitsanwendungen- Verordnung (DiGAV). Germany also has a system to manage the products listed (provisional or final) in the DiGA directory. The manufacturer’s suggested price for compensation is applied during the first year of listing, then a final price is determined through negotiation. Germany has 175 conditions that must be met for listing in the DiGA directory. In addition, proof of positive clinical effects is required for the final listing, so the issue of compensation becomes a necessary consideration when products do not meet minimum standards. Upon reflection of the study’s results, parts that should be considered when introducing the German system to Korea (in terms of listing, compensation, and acceptance) were also analyzed. Especially, we feel the need to develop the price management mechanism during the beginning of this system by confirming the side effects of applying autonomous prices in situations where there is no evidence. The results of this study outline Germany’s digital therapeutics system for better understanding and provide the implications of introducing such related policies domestically in Korea.

HIRA Research 2022; 2(1): 24-35

Review Article 2022-05-31

원격의료 합법화를 고려한 건강보험 정책 제언: 원격진료플랫폼, 원격모니터링기기, 디지털 치료기기 및 재택치료의료기기 중심으로

While social demand for telehealth continues around the world since coronavirus disease 2019, other countries are maintaining and developing health care systems through the activation of telehealth. Korea is also continuously discussing with the government and industry and forming a consensus on the necessity of telehealth. However, the legal problems of telehealth and the application of health insurance for medical expenses are hindering the activation of telehealth. It is insufficient to estimate the value of the medical staff’s time-consuming parts such as initial setting and user and patient education. Assuming that telehealth is legalized, this paper intends to propose the following health insurance policies, focusing on telemedicine platforms, remote monitoring, digital therapeutics, and homecare medical devices, as follows to activate telehealth. Telemedicine platforms are essential when introducing telemedicine, and standardization is necessary to improve the quality of medical services. The health insurance application of remote monitoring should start as soon as possible for user education, the initial setting, analysis, and interpretation. The digital therapeutics and homecare medical device part propose to apply the health care cost. In addition, differentiated pay codes should be reflected in consideration of patient compliance.

HIRA Research 2022; 2(1): 36-46

Original Article 2022-05-31

디지털치료기기 활성화를 위한 정책 수립: 이해당사자 설문을 중심으로

Background: Digital therapeutics, a digital medical device that provides evidence-based therapeutic intervention, is expected to be a promising technology. Digital therapeutics provide great potential to improve the experience and outcomes of patients and medical professionals. The purpose of this study was to suggest policies for revitalizing the field of digital therapeutics.
Methods: This study conducted an online survey on digital therapeutics with stakeholders such as digital therapeutics companies and medical institutions. The questionnaire for the company consisted of a total of 11 questions, including ones on the current development status of their products, requirements for development, and data exchange. The physicians are asked six questions about the field of interest in digital therapeutics and the clinical validation process.
Results: As a result of inquiring about the factors necessary for the development of digital therapeutics on a 5-point scale, the necessity of standard development processes for the product and commercialization guidelines was high (mean±standard deviation [SD]: 4.43±0.76 and 4.14±0.77, respectively). The connectivity between digital therapeutics and electronic medical record/order communication system was in high demand (mean±SD: 4.29±0.73 and 4.21±0.70, respectively). Participants in the companies answered that data exchange such as medical records and results of several tests in clinics are needed. Also, they replied that they could provide the data such as compliance and patients’ behavioral change to medical institutions or governmental regulation organizations.
Conclusion: First, a support program for companies developing digital therapeutics is required to help them prepare for approval and registration of the product. There is also a requirement for a platform system in which digital therapeutics can operate well in a medical institution environment. Finally, it is necessary to develop evaluation methods and indicators suitable for digital therapeutics.

HIRA Research 2022; 2(1): 47-56

Original Article 2022-05-31

의료기관의 수익성과 모바일 기반 Personal Health Record 서비스 도입과의 관계

Background: The purpose of this study is to investigate the relationship between the adoption of a mobile-based personal health record (PHR) system and hospital profitability. Understanding the relationship between a hospital’s profitability and the adoption of a mobile-based PHR system will provide insight into the characteristics of adopters of mobile-based PHR systems.
Methods: Logistic regression analysis was employed to examine the association between hospital profitability and hospital adoption of mobilebased PHR providing the following functions: (1) booking, (2) past or current prescription information, and (3) test results.
Results: We observed a statistically significant association between prescription information service and hospital profitability (operating margin: odds ratio [OR], 0.93; 95% confidence interval [CI], 0.89?0.96; net profit to gross revenues: OR, 0.94; 95% CI, 0.89?0.99). Also, there was a statistically significant relationship between test result service and hospital profitability (operating margin: OR, 0.94; 95% CI, 0.90?0.98; net profit to gross revenues: OR, 0.93; 95% CI, 0.88?0.98). However, we could not observe a significant association between hospital profitability and the provision of booking services.
Conclusion: Further studies are warranted to confirm our findings on the inverse association between hospital profitability and the adoption of mobilebased PHR systems.

HIRA Research 2022; 2(1): 57-64

Original Article 2022-05-31

의료서비스 이용 경험 변화의 분석과 고찰

Background: With the emphasis on people-centered health care systems worldwide, interest in measuring patients' experience in using medical services is increasing. The Medical Service Experience Survey (MSES) is a representative national survey that measures patient experience. For the 2020 and 2021 surveys, we would like to examine the difference in the level of change in patient experience according to whether respondents have secured homogeneity.
Methods: This study analyzed the raw data of the 2020 (n=12,133) and 2021 (n=13,546) MSES. In order to secure the homogeneity of data between years, 8,707 people were selected for analysis by matching 1:1 through propensity score matching. The experience of using medical services was divided into outpatient and inpatient, and each of them was investigated in the four areas (doctor service, nurse service, overall use of medical institutions, and safety). All analyses used STATA ver. 16.1 (Stata Corp., College Station, TX, USA).
Results: It was confirmed that the level of positive experience in the 2 years changed when the statistical significance of the differences in age group (p <0.01), education (p <0.001), type of economic activity (p <0.001), type of medical coverage (p <0.01), household income level (p <0.001), and living area (p <0.05) disappeared. In particular, this trend is more pronounced in inpatient services where the medical service is intensive.
Conclusion: Improving patient experience is one of the goals of the health care system. In order to properly understand the performance of the health care system and to find the direction for improvement through the patient experience, it is necessary to analyze and interpret it using more scientific techniques.

HIRA Research 2022; 2(1): 65-74

Original Article 2022-05-31

치매에 대한 일반인의 지식 평가와 특성 탐색

Background: This research aims to evaluate dementia knowledge and its characteristics according to the socio-demographics of the general public residing in Nam-gu of Ulsan Metropolitan City.
Methods: A face-to-face survey was conducted to identify the total dementia knowledge (general and risk factors) and socio-demographics from September 20th to November 16th, 2021. Proportionate quota sampling was used to select a representative sample of Nam-gu residents. A total of 345 participants’ data were analyzed, using frequency analysis, independent t-test, and one-way analysis of variance.
Results: The average score for the total dementia knowledge was 9.03 of 15, while the average scores for the general and risk factors were 3.54 of 8 and 5.46 of 7, respectively. A group of females under 39-year-old with an education level higher than college scored the highest in the general and risk factors. Educational level was the only socio-demographic factor statistically significant with the average scores of the total (p=0.008) and risk factors (p=0.001) knowledge. Also, the educational level was statistically significant with a few items from the general knowledge and risk factors, such as “Dementia can be diagnosed with brain imaging screening such as computed tomography and magnetic resonance imaging” (p=0.004) and “Smoking has nothing to do with dementia” (p=0.029).
Conclusion: The study results encourage educating and promoting the general dementia knowledge, reflecting its relatively low average score compared to the risk factors. This effort would prevent the delayed diagnosis and treatment due to a lack of awareness of dementia types and symptoms.

HIRA Research 2022; 2(1): 75-94

Original Article 2022-05-31

건강보험 청구자료를 활용한 응급의료 이용현황

Background: The analysis of utilization trends in emergency patients is needed to set an efficient emergency medical system in Korea. We analyzed the number of utilization in emergency patients and their inter-hospital transfer rate.
Methods: We analyzed the National Health Insurance (NHI) claims data in the year of 2014. The 5,714,547 cases were constructed from 8,625,758 claims which were inpatient through the emergency room and outpatient for emergency medicine. The utilization and transfer rates are analyzed by the characteristics of patients and medical facilities.
Results: The transfer rate was 5.1% in total emergency patients and 8.4% in severe patients. The transfer rates were higher in patients with myocardial infarction (12.8%), stroke (13.9%), and severe trauma (11.6%). And 52.6% of transferred patients and 76.8% of transferred severe patients received main procedures at the transferred medical facilities. Patients who had not received main procedures at the first-visit medical facilities were transferred to the hospital located in the same region or Seoul.
Conclusion: As a result of analyzing NHI claims data, there was a difference in the utilization and transferred rate from the results analyzed National Emergency Department Information System (NEDIS) data. It is necessary to establish an information system that can complement the strengths and weaknesses of the NHI claims data and NEDIS.

HIRA Research 2022; 2(1): 95-105

Original Article 2022-05-31

연령에 따른 근무환경 및 의료기관 특성이 간호사 이직에 미치는 영향

Background: Demand for nurses is increasing in various fields of health care services. Despite the increase in the number of nurses, the shortage of nurses has not been solved. The leading cause of the lack of nursing staff is the high turnover rate. This study aims to examine the characteristics of the hospitals and working environment related to nurse turnover and identify the differences by age group.
Methods: In this study, the data reported to the Health Insurance Review and Assessment Service were used. The subjects were nurses who worked in hospitals from 2017 to 2019. Nurse turnover, a dependent variable determined by a continuous work episode, was constructed in consideration of the date of employment and resignation. A total of 194,343 nurse staff in 1,316 hospitals and 245,004 work episodes were examined.
Results: Among the work episodes analyzed, the turnover rate was 40.3%. The turnover of nurses was higher at a younger age, with lower clinical experience, and lower length of stay (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.51?1.63; OR, 2.11; 95% CI, 2.02?2.21; OR, 1.38; 95% CI, 1.33?1.44). Irregular work nurses had a very significant risk of turnover compared to regular work (OR, 3.15; 95% CI, 2.99? 3.33). After stratification by age, irregular work nurses in the working environment and nurse rate grade of the hospital were the main factors affecting a turnover in all age groups.
Conclusion: Nurse turnover was significantly differed according to the hospital characteristics and working environment. In the future, system design or health policy development to reduce the nurse turnover requires a customized design considering age, not introducing a comprehensive system for managing nurses.

HIRA Research 2022; 2(1): 106-119

Original Article 2022-05-31

병원, 의원, 치과의원의 폐업 관련 요인

Background: Sustainability of healthcare delivery system of local communities is based on stable supplies of medical institutions such as small hospitals and clinics. Lack of those facilities critically affect healthcare accessibility of local community residents. The objective of this study is to investigate factors associated with closure of small hospitals and clinics in Korea.
Methods: The units of analysis are small medical institutions: small hospitals, medical clinics, and dental clinics. This study had a retrospective study design and used the secondary health insurance administrative data. The study pulled out the medical institution data closed from January 1, 2020 to December 31, 2021. A total of 52,809 medical facilities were analyzed as the denominator of study population. For statistical analysis, multi-variate logistic regression was used using the event of hospital and clinic closure.
Results: This study found that number of computed tomography (odds ratio [OR], 0.499; 95% confidence interval [CI], 0.316 to 0.790; p=0.003) and magnetic resonance imaging (OR, 0.467; 95% CI. 0.288 to 0.757; p=0.002) were significantly associated with closure of small hospitals, but not in medical and dental clinics. For organizational factors, proportion of medical specialists over generalists and nurses over nurse aids were related with closure of medical (OR, 0.989; 95% CI. 0.978 to 0.999; p=0.04; OR, 0.989; 95% CI. 0.979 to 0.998; p=0.02) and dental clinics (OR, 0.995; 95% CI. 0.993 to 0.997; p<0.001; OR, 0.997; 95% CI. 0.994 to 0.999; p =0.03), respectively. For environmental factors, market competition measured by the Herfindahl-Hirschman Index for hospitals (OR, 0.999; 95% CI. 0.999 to 1.000; p=0.02), the number of medical clinics (OR, 1.001; 95% CI. 1.001 to 1.002; p<0.001), dental clinics (OR, 1.002; 95% CI. 1.002 to 1.003; p<0.001) within local area, and the local population growth rate of clinics (OR, 1.007; 95% CI. 1.001 to 1.013; p=0.03) were significantly associated with medical institution closure.
Conclusion: This study found that several factors were associated with closure of small hospitals, clinics, and dental clinics. Healthcare policy makers need to be aware of these factors to prevent unexpected resource allocation in local communities.

HIRA Research 2022; 2(1): 120-130

Perspective 2022-05-31

코로나 생활치료센터 의사의 역할

The Republic of Korea’s government created community treatment centers (CTCs) to isolate and monitor patients with mild coronavirus disease 2019 (COVID-19) symptoms. Since CTCs offer appropriate clinical triaging and daily monitoring for patients, they are a safe alternative to medical institutions for asymptomatic or mildly symptomatic COVID-19 patients. The aim of this paper is to describe the role of physicians working at CTCs. I worked as a physician at a CTC that re-opened for 24 days in January 2022 as part of a team of three physicians. We developed and revised a manual for the doctors who would take over our work. This paper includes part of the manual and my diary made at that time. A physician at a CTC performs the following tasks: (1) prescribing oral drugs to symptomatic patients, (2) confirming patients’ discharge, (3) giving orders to admitting patients and filling out the electronic medical record, (4) confirming the reports of chest X-ray films taken the previous day, (5) transferring severe cases, (6) confirming patients’ admission, and (7) collecting samples from the nose and throat for polymerase chain reaction testing. Physicians play an important role at CTCs. It is thought that a 2- or 3-week rotation of physicians is too frequent. A 1-week quarantine period at CTCs seems to be too short because the mean period of viral shedding is 23.8±8.7 days (range, 8-49 days). It has been a privilege for me to work as a physician at a CTC.

HIRA Research 2022; 2(1): 131-137

Brief Communication 2022-05-31

COVID-19 Polymerase Chain Reaction 검사 급여기준 변경에 따른 선별진료소 운영현황: 서울시 일개 병원의 사례

Background: To figure out repeated reimbursement criteria changes for polymerase chain reaction (PCR) tests influencing coronavirus disease 2019 (COVID-19) confirmed cases in Korea COVID-19 pandemic era.
Methods: From January 2020 to February 2022, participants who visited a screening center for COVID-19 confirmation in Seoul were included. Data was investigated participant’s reason for getting screening tests and reimbursement rates among the cases. And after the whole investigation period was divided into three groups according to the reimbursement criteria changes, COVID-19 positive ratio was compared in each period with the number of cases that were positive in Korea.
Results: Retrospectively, the period of applying the most recent reimbursement criteria shows the highest positive COVID-19 diagnosis ratio among the periods. Additionally possible cases that have symptoms and epidemiologic correlation were the most positive COVID-19 diagnosis ratio. Most recent reimbursement criteria have a more strict selection than previous criteria, and the result shows that more strict criteria leads to a higher test positivity rate.
Conclusion: According to the results found in the present study, reimbursement criteria for the COVID-19 screening test has changed to be performed more efficiently. If we study the COVID-19 diagnosis rate and quarantine effect according to the PCR test reimbursement criteria, we will be able to develop more efficient screening clinics for infectious diseases in the future.

HIRA Research 2022; 2(1): 138-144

Current Issue Vol. 2 No. 1 May 2022

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