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KMID : 0378019950380040130
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New Medical Journal
1995 Volume.38 No. 4 p.130 ~ p.140
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A Study on Methods of Fee-Schedule Adjustment for Health Insurance in Korea
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Abstract
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One of the most difficult areas for reforming health insurance is to adjust fee schedules as time passes by. Various research institutes have been deeply involved in setting the methodology regar-ding the periodic updating the fees. The paper aims to review those methods having been used by leading research institutes, Korea Productivity Center(KPC), Korea Institute of Health & Social Affairs(KIHASA), Korea Development Institute(KDI), Sam Il Public Account Group and Korea In-stitute of Health Services Management(KIHSM). Sixteen studies have been identified for this purpose.
The KPC study in 1978, the first of these publications, laid the foundation for updating fee schedules in health insurance program. The study recommended that, if the enticed people would be covered under health insurance in 1978, the fee schedule be updated as much as by 44.19% in order not to run into deficit.
The 1987 KIHASA study applied a similar methodology but used five-year longitudinal data from 1980 to 1984. The prevailing interest and loan rates were applied in the calculation of the optimum profit. Thus the study obtained the adjustment rate from the difference between total revenues and total cost which was then divided by the insurance revenue.
The 1987 KPC study tried to calculate the extent of updating the fee schedules when the universal coverage would be achieved in 1989. Ten percent rate of interest was applied for the optimum investment return. The study finally calculated the adjustment rate by using the following formula: (total cost-total revenue)/ total revenue.
The KDI study organized a consortium composed of eminent researchers and university professors. The study was comprised in two adjustment rates basic and supplementary. The former referred to the rate of cost rising at the moment of running a break-even point of the contracted medical facilities. The latter consisted of two parts: the initial adjustment rate due to the implementation of universal coverage,. and the subsequent adjustment rate following the introduction of the insurance health care delivery system. The overall rate of adjustment came from add-up of two rates.
The Sam II Public Account Group used a three-year time series data( 1990-1992). Forty hospitals and twenty clinics were chosen for this study. The study followed the model of KDI study. but as for the final adjustment rate. a different formula was applied: (basic adjustment rate + subsequent adjustment rate due to environmental changes)/ the conversion rate of technical service fees.
The latest study conducted by KIHSM. also used the concept of basic adjustment rate. However, this study tried to identify the real inflation rate of the itemized service component at different medical facilities. The final adjustment rate was the additive combination of the two.
The above study commonly adopted cost accounting methods by each managerial component. However, all studies shared a common weakness in the representativeness of sampled hospitals and clinics, mainly from the limitation of study budget. Also there were no ways to verify the quality of data obtained by the researchers. Thus, the practice of standardized hospital accounting system is the key to improve the adjustment rate of insurance fee schedules.
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