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Han Joong Kim 30 Articles
Socioeconomic Costs of Stroke in Korea: Estimated from the Korea National Health Insurance Claims Database.
Seung ji Lim, Han joong Kim, Chung mo Nam, Hoo sun Chang, Young Hwa Jang, Sera Kim, Hye Young Kang
J Prev Med Public Health. 2009;42(4):251-260.
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  • 42 Crossref
AbstractAbstract PDF
To estimate the annual socioeconomic costs of stroke in Korea in 2005 from a societal perspective. METHODS: We identified those 20 years or older who had at least one national health insurance (NHI) claims record with a primary or a secondary diagnosis of stroke (ICD-10 codes: I60-I69, G45) in 2005. Direct medical costs of the stroke were measured from the NHI claims records. Direct non-medical costs were estimated as transportation costs incurred when visiting the hospitals. Indirect costs were defined as patients' and caregivers' productivity loss associated with office visits or hospitalization. Also, the costs of productivity loss due to premature death from stroke were calculated. RESULTS: A total of 882,143 stroke patients were identified with prevalence for treatment of stroke at 2.44%. The total cost for the treatment of stroke in the nation was estimated to be 3,737 billion Korean won (KRW) which included direct costs at 1,130 billion KRW and indirect costs at 2,606 billion KRW. The per-capita cost of stroke was 3 million KRW for men and 2 million KRW for women. The total national spending for hemorrhagic and ischemic stroke was 1,323 billion KRW and 1,553 billion KRW, respectively, which together consisted of 77.0% of the total cost for stroke. Costs per patient for hemorrhagic and ischemic stroke were estimated at 6 million KRW and 2 million KRW, respectively. CONCLUSIONS: Stroke is a leading public health problem in Korea in terms of the economic burden. The indirect costs were identified as the largest component of the overall cost.


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Vision and Training Strategy for Health Management Specialist.
Han Joong Kim
J Prev Med Public Health. 2006;39(3):195-198.
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AbstractAbstract PDF
The identity crisis of preventive medicine appears to have been deepening. As a solution, it is insisted that preventive medicine should focus on clinical preventive medicine. However, in the field of heath policy and management, the better solution should be found in a serious search for visions and perspectives of its study on population and society. In this regard, the specialist who studies the field can be defined as a medical doctor majoring in public health. In this paper, I first forecasted major socioeconomic changes to occur in medical and public health arena and explored the role of those studying health policy and management. Secondly, I summarized their career paths and main activities in order to establish visions. Finally, I proposed curriculums on health policy and management for medical school undergraduates and for specialists majoring in preventive medicine, respectively.
Changes in Distributive Equity of Health Insurance Contribution Burden.
Hee Chung Kang, Eun Cheol Park, Kyu Sik Lee, Tae Kyu Park, Woo Jin Chung, Han Joong Kim
J Prev Med Public Health. 2005;38(1):107-116.
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AbstractAbstract PDF
We analyzed the changes from 1996 to 2002 in distributive equity of the contribution burden in the Korean National Health Insurance. METHODS: The study subjects were a total of 8, 923 employee households and a total of 7, 296 self-employed households over the period from 1996 to 2002. Those were the households meeting the two criteria as completing each annual survey and having no change in the job of head of the household during that period from the raw data of the Household Income and Expenditure Survey annually conducted by the Korean National Statistical Office. The unit of analysis was a household, and this was the standard for assessing the contribution that is now applied on a monthly basis. Deciles Distribution Ratio, Contribution Concentration Curve and Contribution Concentration Index were estimated as the index of inequality. Multiple regression analysis was conducted to compare the annual ability-to-pay elasticity of the contribution to the reference year of 1996 for three groups (all households, the employee households, and the self-employed households). RESULTS: For the index of inequality, the distributive equity of contribution was improved in all three groups. In particular, the employee group experienced a substantial improvement. Using multiple regression analysis, the ability-to-pay elasticity of the contribution in the employee group significantly increased ( beta=0.232, p< 0.0001) in the year 2002 as compared to the reference year of 1996. The elasticity in the self-employed group also significantly increased ( beta=0.186, p< 0.05), although its change was smaller than that in the employee group. CONCLUSIONS: The employee group had a greater improvement for the distributive equity of the contribution burden than the self-employed group. Within the observation period, there were two important integration reforms: one was the integration of 227 self-employed societies in 1998 and the other was the integration of 139 employee societies in 2000. We expected that the equity of the contribution burden would be improved for the self-employed group since the integration reform of 1998. However, it was not improved for the self-employed group until the year 2000. This result suggests that capturing exactly the beneficiaries' ability-to-pay such as income is the precedent for distributive equity of the contribution burden, although a more sophisticated imposition standard of contribution is needed.
Cost-Utility Analysis of the Cochlear Implant.
Hoo Yeon Lee, Hee Nam Kim, Han Joong Kim, Jae Young Choi, Eun Cheol Park
J Prev Med Public Health. 2004;37(4):353-358.   Published online November 30, 2004
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AbstractAbstract PDF
To determine the quality of life and cost consequences for deaf adults who received a cochlear implant. METHODS: The data from 11 patients, post-lingual deaf adults who received cochlear implants from 1990 to 2002, underwent cost-utility analysis. The average age of the participants was 49.6 years. The main outcomes were direct cost per quality-adjusted life-year (QALY) using the visual analog scale (VAS), health utility index (HUI), EuroQol (EQ-5D), and quality well-being (QWB), with costs and utilities being discounted 3% annually. RESULTS: Recipients had an average of 5.6 years of implant use. Mean VAS scores increased by 0.33, from 0.27 before implantation to 0.60 at survey. HUI scores increased by 0.36, from 0.29 to 0.65, EQ-5D scores increased by 0.26, from 0.52 to 0.78, and QWB scores increased by 0.16, from 0.45 to 0.61. Discounted direct costs were $22, 320, yielding $19, 223/QALY using VAS, $17, 387/QALY using HUI, $24, 604/QALY using EQ-5D, and $40, 474/QALY using QWB. Cost-utility ratios using VAS, HUI, and EQ-5D were all below $25, 000 per QALY, except using QWB. CONCLUSION: Cochlear implants in post-lingual deaf adult have a positive effect on quality of life at reasonable direct costs and appear to produce a net saving to society.
Analysis of Socioeconomic Costs of Smoking in Korea.
Han Joong Kim, Tae Kyu Park, Sun Ha Jee, Hye Young Kang, Chung Mo Nam
Korean J Prev Med. 2001;34(3):183-190.
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AbstractAbstract PDF
To estimate the annual economic costs attributable to cigarette smoking in Korea. METHODS: The costs were classified as being direct medical and non-medical costs, indirect costs and others. We focused on those costs related that are incurred in the treatment of selected diseases (cardiovascular diseases, respiratory diseases, and cancers), which have been proven to be caused by smoking. In addition to the basic costs of treatment, the additional amount of costs occurred due to smoking was obtained by computing the population attributable risk (PAR%) caused by smoking. To compute the PAR%, relative risks of smoking to the number of outpatient visits, hospitalizations, and the death were estimated using the Cox proportional hazard model, respectively. Our major data source was the 'Korea Medical Insurance Corporation (KMIC) cohort study,' which was composed of a total of 115,682 male and 67,932 female beneficiaries who had complete records of their smoking histories in the year of 1992. RESULTS: The annual costs that could be attributable to smoking were estimated to be in the range of 2,847,500 million Won to 3,959,100 million Won. The maximum estimate of 3,959,100 million Won includes 233,100 million Won for medical costs, 5,100 million Won for transportation costs, 27,600 million Won for care giver's economic costs, 69,100 million Won in productivity loss, 3,435,000 million Won lost because of premature death, 172,100 million Won in costs resulting from passive smoke inhalation and 17,100 million Won for costs that resulted from fires that were caused by careless smoking. CONCLUSION: Our study confirms that the magnitude of the economic burden of smoking to Korean society is substantial. Therefore, this study provides strong evidence that there is a strong need for a national policy of tobacco control in Korea.
Time Series Observations of Outcome Variables and the Factors Associated with the Improvement in the Patient Outcomes of Cataract Surgery.
Han Joong Kim, Eun Cheol Park, Yoon Jung Choi, Hyung Gon Kang
Korean J Prev Med. 2001;34(2):175-181.
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AbstractAbstract PDF
To compare the multiple outcomes of patients with cataract surgery at perioperative time, 3-4 months and 12 months after surgery and to assess patient outcomes associated with visual improvement(visual acuity of operated eye, visual function-14(VF-14), symptom score). METHODS: For this assessment, a prospective study was conducted with 389 patients who had undergone cataract surgery for either one eye or both eyes. The surgery was performed by 20 ophthalmologists who were practicing at university hospitals and general hospitals. Patients were interviewed and clinical data were obtained. Doctors were questioned with self-reported questionnaire forms. Medical records were examined in order to measure variables related to the surgical process such as surgical methods and ocular comorbidity. The survey was conducted at 4 stages : preoperative time(389 cases), perioperative time(344 cases, 88.4%), postoperative 3-4 months (343 cases, 88.2%), and postoperative 12 months (281 cases, 72.2%). After excluding cases with incomplete data, 198 cases were enrolled in the study. Patient outcomes was measured for any improvement in the functional outcomes(visual acuity of operated eye, visual function, symptom score) at postoperative 3-4 months. RESULTS: The visual acuity(operated, weighted average), symptom score, VF-14 score, satisfaction with vision, and subjective health status were shown to be improved at the perioperative time, postoperative 3-4 months and 12 months. An improvement in the Snellen visual acuity score was observed in 190 patients(96.0%), whereas improvements of the VF-14 score and cataract symptom score were observed in 151 patients(76.3%) and 179 patients(90.4%), respectively. All three outcome measures demonstrated improvement in 137 patients(69.2%). The improvement of the three functional outcomes at 3-4 months after receiving surgery was associated with a lower level of visual function and a higher level of cataract symptom score at perioperative time, as well as a greater experience level of the surgeon. CONCLUSIONS: In this study, the estimates of the proportion of patients benefiting from cataract surgery varied with the outcome measure of benefit. Preoperative VF-14 score, a measure of functional impairment related to vision, and symptom score may be better measures of the benefit derived from cataract surgery than the change in visual acuity.
Predictors of Successful Control for Selfishness, Dishonesty, Resentment, and Fear (SDRF) among Korean Alcoholics Anonymous Members.
Ein Soon Shin, Han Joong Kim, Yoon Chul Chung
Korean J Prev Med. 2001;34(1):73-79.
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AbstractAbstract PDF
To examine predictors of successful control for selfishness, dishonesty, resentment, and fear(SDRF) among Korean Alcoholics Anonymous(AA) members. METHODS: This study was a cross-sectional study. The study group included members from 18 different AA groups which were enrolled in the Korean AA Association in 1998. 207 out of 300 self administered questionnaires were completed by AA members (response rate 69.0%). Alcoholics who attended AA meetings were divided into two groups according to their self reported level of success in SDRF control; one with very successful experience after AA participation and the other with little or no success. In this study, the general characteristics, AA activities, relapse experience, and degree of effort exerted for SDRF control were compared between two groups. In order to study predictors of successful SDRF control after joining AA, 4 logistic regression analyses were performed for each of the 4 SDRF indices. RESULTS: The proportion of those reporting a very successful experience was 19.9% for selfishness, 20.7% for dishonesty, 25.5% for resentment, and 24.7% for fear. After control for the effect of general characteristics, the practice of the 12th step(taking alcoholics to an AA meeting after conveying messages) was found to be a significant predictor for the successful control of both selfishness(OR=6.04) and the dishonesty(OR=7.77). And individuals making every effort for SDRF control showed more successful control of selfishness(OR=4.10), dishonesty(OR=4.01), and fear(OR=34.89). CONCLUSIONS: Bivariate and multivariate analyses demonstrated that especially practicing the 12th step and making every effort themselves, may help alcoholics to control SDRF successfully after joining AA.
Cost-benefit Analysis of Mandatory Prescription in Korea.
Young Keon Jee, Han Joong Kim, Eun Cheol Park, Hye Young Kang
Korean J Prev Med. 2000;33(4):484-494.
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AbstractAbstract PDF
To evaluate the relative benefits and the costs associated with the introduction of the new pharmaceutical provision called 'Mandatory Prescription Syste m' which separates the role of physicians from that of pharmacists with respect to the prescription and dispensation of from the perspective of consumers (i.e., patients). METHODS: The costs of the system were measured by considering both direct and indirect costs. Direct costs included additional payments for ambulatory care and dispensing fees that occurred under the new system. Indirect costs consisted of transportation expenses and costs related to time spent for physician consultation, waiting for the prescriptions to be filled, and extra traveling. Benefits identified in this study were the reduction of drug misuse and overuse, and the overall decrease in drug consumption among the Korean population. Sensitivity analysis was performed for the inclusion of benefits for outpatients of hospitals, price elasticity, and increased fees for established patients. RESULTS: The net benefit was estimated to be about minus 1,862 billion won and the benefit-cost ratio was 0.478. This indicates that the costs of 'Mandatory Prescription' outweigh its benefits, relative to the previous system. The sensitivity analysis results for all the variables considered in this study consistently showed the benefit-cost ratio to be less than 1. CONCLUSION: The results of this study suggest that implementing Mandatory Prescription System in Korea might be inefficient from the consumer's perspective. The results of this study do not coincide with the results of previous studies, presumably because of the differences in study design and in which items of costs and benefits were considered.
Factors Affecting the Participation Rate in the Health Screening Program of Medical Insurance.
Sung Tae Youn, Han Joong Kim, Sun Ha Jee, Il Suh, Heechoul Ohrr
Korean J Prev Med. 2000;33(2):150-156.
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AbstractAbstract PDF
To analyze the factors affecting the participation rate in the health screening program of medical insurance. METHOD: We investigated the factors associated with the participation rate in the health screening program in Korea. Data were collected at the aggregate level from 145 employee health insurance societies and 227 self-employed health insurance societies from 1995 to 1997. Data were also collected at the individual level from four health insurance societies. This study hypothesized that the participation rate of the health screening program was related to 1) the characteristics of its members and the size of the health insurance society; 2) the specifications of the health screening program; 3) the venue of the health screening institution and the interests of individuals in the health screening program; and 4) the activities of the health insurance society. We used bivariate and multiple regression models to examine the factors on the participation rate of the health screening program. RESULTS: First, in the case of dependents of on employee health insurance society, the ratio of dependents 40 years old and over, the average monthly contribution per household, the interest and satisfaction level of individuals in health screening, and the level of refunds for over-payment were all associated with the participation rate in the health screening program, accounting for 54.4% of the participation rate. Second, in case of those insured by the self-employed health insurance society, the interest and satisfaction level of individuals in health screening, the level of refunds for over-payment, and the performance level of on-the-spot health screening were statistically significant, accounting for 40.1% of the participation rate. CONCLUSION: The factors concerning the participation rate in the health screening program of medical insurance, in both a health insurance society and for individuals, were closely related to the age and gender of individuals and household contributions.
Statistical Methods for Multivariate Missing Data in Health Survey Research.
Dong Kee Kim, Eun Cheol Park, Myong Sei Sohn, Han Joong Kim, Hyung Uk Park, Chae Hyung Ahn, Jong Gun Lim, Ki Jun Song
Korean J Prev Med. 1998;31(4):875-884.
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AbstractAbstract PDF
Missing observations are common in medical research and health survey research. Several statistical methods to handle the missing data problem have been proposed. The EM algorithm (Expectation-Maximization algorithm) is one of the ways of efficiently handling the missing data problem based on sufficient statistics. In this paper, we developed statistical models and methods for survey data with multivariate missing observations. Especially, we adopted the Em algorithm to handle the multivariate missing observations. We assume that the multivariate observations follow a multivariate normal distribution, where the mean vector and the covariance matrix are primarily of interest. We applied the proposed statistical method to analyze data from a health survey. The data set we used came from a physician survey on Resource-Based Relative Value Scale(RBRVS). In addition to the EM algorithm, we applied the complete case analysis, which used only completely observed cases, and the available case analysis, which utilizes all available information. The residual and normal probability plots were evaluated to access the assumption of normality. We found that the residual sum of squares from the EM algorithm was smaller than those of the complete-case and the available-case analyses.
Analysis of influencing factors on self-employed physician's income.
Woong Sub Park, Han Joong Kim, Myong Sei Sohn, Eun Cheol Park
Korean J Prev Med. 1998;31(4):770-785.
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This study describes the relation of physician's income and price of medical service and social welfare through microeconomic view, reviews the literature of influencing factor on physician's income, and it describes general distribution of physician's income, and analyzes influencing factor of physician's income. A total of 844 persons responded to the mail survey, through stratified sampling by 23 branches of medical society in Korean RBRVS study. The design of the study is cross sectional study, and the unit of analysis is a physician. To examine the change of average income per month, multiple regression was used to test the change according to physician's characteristics, demographic characteristics, scale of clinic(or hospital), average intensity of ordinary work, and specialty. The major findings of this study are as follows; 1. As for self-employed physicians, the difference of average income per month among specialties was 4,850,000won, but the difference was 6,020,000won under the control of control variables, and average income per month was significantly higher for physicians who had sick-beds than physicians who had no sick-beds. 2. The number of average out-patients per month and number of nurses and nursing aides significantly positively associated, but the number of physician significantly negatively associated with average income per month. In conclusion, the number of out-patient and number of nurses and nursing aides is the major influencing factor, and the difference of average income per month among specialties existed in self-employed physicians. So this study suggests basic hypothesis that the price of medical service and supply of physician by specialties are not pertinent. Being a cross-sectional study, this study can not suggest causal explanations. In the future, further study is needed for causal explanations.
The Difference in Attitude toward Medical Care between Patients and Physicians.
Myung Geun Kang, Jong Ku Park, Han Joong Kim, Myong Sei Sohn, Dal Rae Kim
Korean J Prev Med. 1998;31(3):516-539.
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The objective of this study is to identify the difference in attitude toward medical care between patients who visited a university hospital or an oriental medical hospital of oriental medical college, and physicians who engaged in the same hospitals. The subjects of this study were 397 cases who agreed to respond the prepared questionnaire, including 288 patients(146 university hospital utilizers and 142 utilizers for an oriental medical hospital) and 109 physicians(76 physicians and 33 oriental medical doctors). The attitude toward medical care was measured by the structured questionnaire developed for this study, which had high validity and reliability according to factor analysis, item discriminant validity, and Cronbach's alpha coefficients. On the criteria of mean value of care and cure score, the attitude toward medical care was classified into 4 groups encompassing a group with dependent attitude on medical care, a group with skeptical attitude toward it, a group with cure-oriented attitude, and a group with care- preferred attitude. The results of chi-square test, discriminant analysis, and logistic regression analysis were as follows; patients who visited a university hospital, patients who visited an oriental hospital, physicians, and oriental medical doctors included in the group with dependent attitude, the group with cure-oriented attitude, the group with skeptical attitude, and the group with care-preferred attitude, retrospectively. Among the subdomains of care and cure domains, which classified in reference to the result of factor analysis on pilot study, those that patients ranked more importantly than physicians were 'the importance of medical equipment for diagnosis and treatment', 'authority of physician, 'aggressiveness of treatment', 'information giving', 'personal interest' in the case of western medicine. In the case of oriental medicine, those were 'the importance of equipment for diagnosis and treatment', 'aggressiveness of treatment', 'amenities and accessibility', 'coordination of medical staff'. Both physicans and patients put the subdomain, 'physicians' medical knowledge and skillfulness' on the highest rank. The differences in ranking the important attributes of medical care between patients and physicians were apparent in the area of an 'importance of medical equipment for diagnosis and treatment' and so on. It meant that patient had over-expectation on medical care and suggested that the policy on demand side such as the development and dissemination of an evidence-based recommendation protocol for health care consumers might be important in Korea. In addition, regarding the attitude of physicians, during the medical education and training it may be necessary to emphasize the aspect of 'care' of medical care rather than 'cure'. In planning on heath care delivery system, it should be considered that there is a difference in the attitude toward medical care between western medicine and oriental medicine as well as between health care providers and consumers. We expect that more valid measurement tool be developed in this area, which may be major limitation of this study and that this kind of research be expanded into the non-academic settings.
The Development of Classification System of Medical Procedures in Korea.
Hyoung Wook Park, Myongsei Sohn, Han Joong Kim, Eun Cheol Park, Seung Hum Yu
Korean J Prev Med. 1996;29(4):877-897.
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In recent years, the Korean Medical Association has undertaken the feat of establishing the Korean Standard Terminology of Medical Procedures with the dedicated help of 32 medical academic societies. However, because the project is being conducted by several different circles, it has yet to see a clear system of classification. This thesis, therefore, proposes the three principles of scientific properties, usefulness and ideology as the basis for classification system and has developed the Classification System of Medical Procedures in Korea upon their foundation. The methodology and organization of this thesis as follows. First, by adopting scientific classification system of Feinstein(1988), an analysis of the classification systems of the medical procedures in the United States, Japan, Taiwan, Who Was carried out to reveal the framework and the basic principles in each system. Second, the direction of classification system has been constructed by applying the normative principle of medical field in order to show the future direction of the medical field and realize its ideology. Third, a finalized framework for the classification system will be presented as based on the direction of classification system. Of the three basis principles mentioned above, the analysis on the principles of usefulness was left out of this thesis due to the difficulty of establishing specific standards of analysis. The results of the study are as follows. The overall structure of the thesis is aimed at showing the 'Prevention-Therapy-Rehabilitation' quality of comprehensive health care and consists of six chapters; I. Prevention and Health Promotion. II. Evaluation and Management . III. Diagnostic Procedures. IV. Endoscopy. V. Therapeutic Procedures. VI. Rehabilitation. Chapter three Diagnostic Procedures is divided into four parts; Functional Diagnosis, Visual Diagnosis, Pathological Diagnosis, Biopsy and Sampling. Chapter five Therapeutic Procedures is divided into Psychiatry, Non-Invasive Therapy, Invasive Therapy, Anaesthesia and Radiation Oncology. Of these sub-divisions, Functional Diagnosis, Biopsy and Sampling, Endoscopy and Invasive Therapy employs the anatomical system of classification. On the other hand, Visual Diagnosis, Pathological Diagnosis, Anesthesia and Diagnostic Radiology, namely those divisions in which there is little or no overlapping in services with other divisions, used the classification system of its own division. The classification system introduced in this thesis can be further supplemented through the use of the cluster analysis by incorporating the advice and assistance of other specialists.
The Economic Impact of a Rural Hospital to local Economy.
Im Ok Kang, Sun Hee Lee, Han Joong Kim
Korean J Prev Med. 1996;29(4):831-842.
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Demand for high quality medical care has recently been increasing in step with high level of income and education. Patients prefer the use of large general hospitals to small community hospitals. Large hospitals, usually located at urban area, expand their capacities to cope with the increasing demand, therefore, they easily secure revenue necessary for growth and development of hospitals. However, small community hospitals are facing with serious financial difficulties caused from the reduction of patients in one hand and the inflation of cost in another. If small rural hospitals were closed, the closure would have negative impacts on local economies in addition to the decrease in access to medical care. Community leaders should have an insight on the contribution of community hospitals to local economies. They could make a rational decision on the hospital closure only with the understanding of hospital's contribution to the community. This study is designed to develop an economic model to estimate the contribution of rural hospital to local economies, and also to apply this model with a specific hospital. The contribution of a hospital to local economies consists of two elements, direct effect and multiplier effects. The direct impacts include hospital's local purchasing power, employee's local purchasing power, and the consumption of patients coming from outside the community. The direct impact induces multiplication effect in the local economy. The seed money invested to other industries grows through economic activities in the economy. The seed money invested to other industries grows through economic activities in the region. This study estimated the direct effect with the data of expenditure of the case hospital. The total effect was calculated by multiplied the direct effect with a multiplier. The multiplier was drown from the ratio of marginal propensity of income and expenditure. Beside the estimation of the total impacts, the economic effect from the external resources was also analyzed by the use of the ratio of patients coming outside the region. The results are as follows. 1. The direct economic contribution of the hospital to the local economy is 1,104 million won. 2. The value of multiplier in the region is 2.976. 3. The total economic effect is 3,286 million won, and the multiplication effect is 2,182 million won. 4. The economic contribution from the external resources is 245 million won which is 7.5% of the total economic effect.
A methodological study on simplifying claims review system in medical insurance.
Suk Il Kim, Hyung Gon Kang, Han Joong Kim, Young Moon Chae, Myongsei Sohn, Myung Keun Lee
Korean J Prev Med. 1995;28(3):640-650.
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After the introduction of National Medical Insurance in 1989, the medical demand has rapidly increased. The impact of increased medical demand was followed by an increase in the number of claims in need of review. We studied a new, fair method for reducing the number of claims reviewed. we analysed 90,583 outpatient claims submitted between september and october; claims were made for services given August of 1994. We finally suggested a screening system for claims review using a statistical method of discriminant analysis of the medical costs. The results were as follows. 1. In the cut-off group, age, days of medication, number of hospital or clinic visits, and total change were significantly high The cut-off rates according to the hospital-type and existence of accompanied disease were significantly different. 2. According to ICD, the cut-off rate was highest in peripheral enthesopathies and allied syndromes(20.76%), lowest in acute sinusitis(0.93%). The mean charges were significantly different according to ICD and existence of cut-off. 3. we build discriminant functions by ICD with such discriminant variables as patient age, sex, existence of accompanied disease, number of hospital or clinic visits, and 9 detailed hospital or clinic charges included in claim. 4. we applied the discriminant function for screening those claims that were expected to be cut-off. The sensitivities comprised from 40% to 70%, and specificities from 70% to 95% by ICD. Acute rhinitis had highest sensitivity(100.00%)and other local infections of skin and subcutaneous tissue had highest specificity(98.45%). The excepted number of cut-off was 17,762(19.61%). The total sensitivity was 49.62%, the total specificity was 82.57% and the error rate was 19.66%. We lacked economic analysis such as cost-benefit analysis. But, if the few method of screening claims using discriminant analysis were applied, the number of claims in need of review will reduce considerably.
Comparison of work measures for some physician services in Obstetrics & Gynecology.
Yeong Joo Hur, Myong Sei Sohn, Eun Cgeol Park, Hyung Gon Kang, Han Joong Kim
Korean J Prev Med. 1995;28(3):623-639.
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We have never seen any method to cope basically with complicated situation and problems around medical reimbursement rates here in Korea since 1977 witnessed by the beginning of medical insurance. By the way researchers concerned are beginning to propose some kinds of innovative and detailed ideas to government these days. They are Diagnosis-related group(DRG)and Resource-based relative value scale(RBRVS). In the light of this situation it is so encouraging that our government can come up with that and move. In case of RBRVS research we have already been reaching even to the level of reviewing and revising methodology for its further development after naive pilot study on internal medicine and general surgery last year. However there might be something different conditions between USA and Korea to apply the same Dr. Hsiao's method and it must be vital to check so called 'total work approach' compared with 'intra-service work approach' before expanding to the whole medical fields. According to the 'Intra-service approach', the physician's work is supposed to be divided into three sub-works by the name of intraservice work, pre, and post service work. These sub-works, again should be merged together to be the pre-postwork subset through some statistical methods of the estimation process applied by Dr. Hsiao's methodology in RBRVS development later on. But in this paper that estimation process was not taken because we could have real values for all of those surveyed items related to just one specialty, OB & GY. Instead, we used some statistical comparison procedures relevant to demographic characteristics, reliability & validity and correlation analysis with American RVU(Relative value unit) between the total work and merged total work from intraservice work approach. The unit of analysis was individual physicians of OB & GY and 300 physicians were selected for each approach through statistical sampling method based on national population of OB & GY physicians in korea. And also with the thankful help of Advisory committee under Korean Association of OB & GY, questionnaires were made and mailed to the subjects, two times. As a result there were not any statistically significant differences in demographic characteristics between the two approaches except for the variable 'Response time for the questionnaire', but in other sections of comparisons, response rate, representative values, reliability & validity test, correlation analysis with American RVU, all showed 'Total approach' was not only more rational and statistically meaningful than ,'Intra-service approach' but also had considerable merits. But we are not absolutely sure about this paper's robustness. Because of some limitations, we'd rather like to suggest further researches should be followed. In that sense the first thing would be a research for the influence of doctor's haracteristics, especially 'frequency' on the rating of work and the way to define total work more clearly.
Impacts of Implementation of Patient Referral System in terms of Medical Expenditures and Medical Utilization.
Sang Hyuk Jung, Han Joong Kim
Korean J Prev Med. 1995;28(1):207-224.
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A new medical delivery system which regulated outpatient department(OPD) use from tertiary care hospitals was adopted in 1989. Under the new system, patients using tertiary care hospital OPD without referral slip from clinics or hospital could not get any insuranced benefit for the services received from the tertiary care hospital. This study was conducted to evaluate the Patient Referral System(PRS) with respect to health care expenditures and utilization. Two data sets were used in this study. One was monthly data set(from January 1986 to December 1992)from the Annual Report of Korea Medical Insurance Corporation(KMIC). The other was monthly joint data set composed of personal data of which 10% were selected randomly with their utilization data of KMIC from January 1988 to December 1992. The data were analyzed by time-series intervention model of SAS-ETS. The results of this study were as follows: 1. There was no statistically significant changes in per capita expenditures following PRS. 2. Utilization episodes per capita was increased statistically significantly after implementation of PRS. The use of clinics and hospitals increased significantly, whereas in tertiary care hospitals the use decreased significantly immediately after implementation of PRS and increased afterwards. 3. Follow-up visits per episode were decreased statistically significantly after implementation of PRS. The decrease of follow-up visits per episode were remarkable in clinics and hospitals, whereas in tertiary care hospitals it was increased significantly after implementation of PRS. 4. There was no statistically significant changes in prescribing days per episode following PRS. Futhermore, clinics and hospitals showed a statistically significant decrease in prescribing days per episode, whereas in tertiary care hospital it shower statistically significant increase after implementation of PRS. 5. Except high income class, the use of tertiary care hospitals showed statistically significant decrease after implementation of PRS. The degree of decrease in the use of tertiary card hospitals was inversely proportional to income. These results suggest that the PRS policy was not efficient because per capita expenditures did not decrease, and was not effective because utilization episodes per capita, follow-up visits per episode, and prescribing days per episode were not predictable and failed to show proper utilization. It was somewhat positive that utilization episodes per capita were decreased temporarily in tertiary card hospitals. And PRS policy was not appropriate because utilization episodes per capita was different among income groups. In conclusion, the PRS should be revised for initial goal attainment of cost containment and proper health care utilization.
Impacts of the Implementation of the DRG Based Prospective Payment System on the Medicare Expenditures.
Han Joong Kim, Chung Mo Nam
Korean J Prev Med. 1994;27(1):107-116.
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The united states adopted DRG based prospective payment system (PPS) in order to control the inflation of health care costs. No study used statistical test while many studies reported the cost containing effect of the PPS. To study impacts of the PPS on the Medicare expenditure, this study set the following three hypotheses: (l) The PPS decelerated the increase in the hospital expenditure (part A), (2) the PPS accelerated the increase in the expenditure of outpatients and physicians (part B), (3) the increase in total expenditure was decelerated inspite of the spill over (substitution) effect because saving in the part A expenditure were greater than losses in the part B expenditure. The dependent variables are per capita hospital expenditure, per capita part B expenditure, and per capita total expenditure for the Medicare beneficiaries. An intervention analysis, which added intervention effect to the time series variation on the Box-Jenkins model, was used. The observations included 120 months from 1978 to 1987. The results are as follows: (l) The annual increase in the per capita part A expenditure was $5.11 after the implementation of DRG where as that before the PPS had been $11.1. The effect of the reduction ($5.99) was statistically significant (t=-3.9). (2) The spill over (substitution) effect existed because the annual increase in the per capita part B expenditure was accelerated by $l.73 (t=l.91) after the implementation of the PPS. (3) The increase in the total Medicine expenditure per capita was reduced by $4.26(t=-2.19) because the spill over effect was less than cost savings in the Part A expenditure.
An Analysis on Factors Relating to Fiscal Deficit for Regional Health Insurance Program in Korea.
Han Joong Kim, Woo Hyun Cho, Sun Hee Lee, Hyung Kon Kang, Yang Kyun Kim
Korean J Prev Med. 1992;25(4):399-412.
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This study was designed to investigate factors relating to fiscal deficit for regional health insurance. The financial statements for the fiscal year 1990 of nationwide 254 regional medical insurance societies were analyzed. Important findings are summarized below: 1. There were differences in the main reason for the financial deficit among regions when deficit and surplus societies were compared by regions. The total revenue per enrollee, especially revenue from the premium contribution of a deficit society was significantly smaller than that of a surplus society in large cities and counties. On the other hand, the total expenditure per enrollee of a deficit society was larger than that of a surplus society in small cities. 2. Both low premium irate at the beginning of health insurance program and less effort to increase the premium rate were main factors for the smaller revenue from the contribution of a deficit society in large cities and counties. 3. Larger expenditures per covered person of a deficit society in small cities were explained with larger medical expenditures especially for out-patients services rather than larger administrative expenses. 4. A regression analysis showed that utilization rates in out-patient services were significantly associated with income and numbers of total medical care institution per capita within a region where a health insurance society located. Also expenses paid by insurer per visit were associated with the proportion of utilization for tertiary care hospitals as well as the proportion of utilization of public health centers.
Factors affecting the price-reduction rates among the insurance medicines.
Hyoung Joong Kim, Woo Hyun Cho, Han Joong Kim, Byung Yool Cheon
Korean J Prev Med. 1992;25(1):64-72.
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To provide the information necessary for the insurance medicine management plan, price discount rates among the insurance medicines were studied. A total of 2,107 items of insurance medicine of which prices were discounted via government inspections of real transactional process of insurance medicine were analysed. The conclusions are as follows; 1. Among the variables relevant to the characteristics of manufacturers, price discount rates of insurance medicines were statistically significant with production rankings of manufacturers, incorporation year, existence of investments by foreign corporation, existence of a research institute, and enrollment in the exchange. And among the variables relevant to the properties of medicines, the number of enrolled items which have the same components, classification, the date of new enrollment, the sales of items, and the number of raw materials in the items were statistically significant. 2. Stepwide multiple regression was done to identify the factors which affect the price discount rates of insurance medicines. The number of enrolled items which have the same components, production rankings of manufactures, classification number (medicines for function of tissue cells), incorporation year (1940-1949), existence of investments by foreign corporations, classification number (anti-germ medicines), number of raw materials in the items, the sales of items, and medicines whose major objective is not treatment were significant variables and the R2-value for these variables was 21.2%. Considering all of the above results, for management of insurance medicines, it seems important that the real transactional prices of insurance medicines should be identified systematically, focusing on the properties which affect the price discount rates of insurance medicines.
A Study on the Criteria for Selection of Medical Care Facilities.
Woo Hyun Cho, Han Joong Kim, Sun Hee Lee
Korean J Prev Med. 1992;25(1):53-63.
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There are increasing interest and need for information on health care consumer with the significance of hospital marketing and strategic planning being increasingly emphasized. This study was conducted to investigate the criteria for selection of medical facilities according to the characteristics of health care consumer by the types of medical services on a sample of 1,500 population aged 20 years and above. Major findings are as follows; 1. When considering the criteria for selection of medical facilities into two factors, namely, quality or convenience factors, convenience factor was the major contributor for outpatient and dental services whereas it was quality factor for inpatient services. 2. Females and those residing in large cities selected medical facilities based on convenience factor in the outpatient services. In the case of inpatient service, persons who considered their present health status to be good and whose ages were 50 years old and above choose medical facilities based on quality factor. 3. Persons who considered medical facilities to be profit-making tended to choose medical facilities based on convenience factor for outpatient services. There were no differences in the cases of inpatient and dental services. 4. There was no significant difference on the criteria for selection of medical facilities according to the decision maker for selection or trust on medical facilities. On the use of health service information, selection of medical facilities was based on qPality factor for those who made more use of the information in the cases of outpatient and dental services. 5. Analysis using the logistic regression model on the criteria for the selection of medical facilities with the characteristics of health care consumer as independent variables was performed. The selection of medical facilities was significantly related with residential area, sex, and use of information on medical facilities for outpatient services and with age, average monthly income, and perception of health status for inpatient services. For dental services significant association with residential area and use of information on medical facilities was seen. The results of this study, despite some limitations, can be used as baseline data for marketing and strategic planning of hospital management.
A quentitative model for the projection of health expenditure.
Han Joong Kim, Young Doo Lee, Chung Mo Nam
Korean J Prev Med. 1991;24(1):29-36.
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A multiple regression analysis using ordinary least square (OLS) is frequently used for the projection of healt expenditure as well as for the identification of factors affecting health care costs. Data for the analysis often have mixed characteristics of time series and cross section. Parameters as a result of OLS estimation, in this case, are no longer the best linear unbiased estimators (BLUE) because the data do not satisfy basic assumptions of regression analysis. The study theoretically examined statistical problems induced when OLS estimation was applied with the time series cross section data. Then both the OLS regression and time series cross section regression (TSCS regression) were applied to the same empirical data. Finally, the difference in parameters between the two estimations were explained through residual analysis.
The recent trend and determinants of service diversification in Korean hospitals.
Sun Hee Lee, Han Joong Kim, Woo Hyun Cho
Korean J Prev Med. 1991;24(1):16-28.
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Service diversification is recognized as an important strategy against turbulent environmental change. This study is designed to find out the trend of service diversification in Korean health care organizations and also to identify factors associated with the degree of service diversification. Data were collected from 69 hospitals out of 71 hospitals with over 300 beds. Important findings are summarized below. 1. Types of diversification are closely related to hospital size. Large hospitals have a tendency to provide sophisticated service requiring specialized skills and equipment, while small hospital have concentrated their efforts on health screening programs. 2. The more competitive and bigger hospitals are, the greater number of services that provide. Also, hospitals operating rational management information systems provide more services. Contrary to the expectation, hospitals with a low performance during last 3 years showed more service diversification. 3. A trend of more diversification was observed in hospitals whose chief executive officer used a prospector strategy. 4. A multiple regression analysis revealed that bed size, competitive environment, degree of rational management, and the growth pattern were significantly associated with teh service diversification.
Analysis of charges per case by hospital characteristics: In regard to acute appendicitis and NSVD.
Sang Hyuk Jung, Seung Hum Yu, Han Joong Kim
Korean J Prev Med. 1990;23(2):216-223.
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To identify the factors influencing the charges per case of acute appendicitis and normal spontaneous vaginal delivery (NSVD), the personal data-base files and hospital-characteristics-reporting data files of Korea Medical Insurance Corporation were analyzed. One hundred and twenty-nine institutions were selected. The results of this study were as follows: 1. The differences of charges per case with respect to hospital ownership, location, and equipment levels were statistically significant. 2. The results of multiple regression analysis revealed that bed capacity was the most significant variable in both diseases. 3. Ownership was significant variable in acute appendicitis. In NSVD, ownership and hospital equipment level were statistically significant. In conclusion, bed capacity was statistically the most significant variable in the analysis of charges per case. And we thought that the results of this study would influence the policy of the hospital bed supply.
An Analysis of Determinants of Medical Cost Inflation using both Deterministic and Stochastic Models.
Han Joong Kim, Ki Hong Chun
Korean J Prev Med. 1989;22(4):542-554.
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The skyrocketing inflation of medical costs has become a major health problem among most developed countries. Korea, which recently covered the entire population with National Health Insurance, is facing the same problem. The proportion of health expenditure to GNP has increased from 3% to 4.8% during the last decade. This was remarkable, if we consider the rapid economic growth during that time. A few policy analysts began to raise cost containment as an agenda, after recognizing the importance of medical cost inflation. In order to prepare an appropriate alternative for the agenda, it is necessary to find out reasons for the cost inflation. Then, we should focus on the reasons which are controllable, and those whose control are socially desirable. This study is designed to articulate the theory of medical cost inflation through literature reviews, to find out reasons for cost inflation, by analyzing aggregated data with a deterministic model. Finally to identify determinants of changes in both medical demand and service intensity which are major reasons for cost inflation. The reasons for cost inflation are classified into cost push inflation and demand pull inflation. The former consists of increases in price and intensity of services, while the latter is made of consumer derived demand and supplier induced demand. We used a time series (1983-1987), and cross sectional (over regions) data of health insurance. The deterministic model reveals, that an increase in service intensity is a major cause of inflation in the case of inpatient care, while, more utilization, is a primary attribute in the case of physician visits. Multiple regression analysis shows that an increase in hospital beds is a leading explanatory variable for the increase in hospital care. It also reveals, that an introduction of a deductible clause, an increase in hospital beds and degree of urbanization, are statistically significant variables explaining physician visits. The results are consistent with the existing theory. The magnitude of service intensity is influenced by the level of co-payment, the proportion of old age and an increase in co-payment. In short, an increase in co-payment the utilization, but it induced more intensities or services. We can conclude that the strict fee regulation or increase in the level of co-payment can not be an effective measure for cost containment under the fee for service system. Because the provider can react against the regulation by inducing more services.
Economic Benefits of Implementing National Health Insurance by Measurement of Changes in the Consumer's Surplus.
Han Joong Kim, Hae Jong Lee
Korean J Prev Med. 1989;22(3):398-405.
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A change in the consumer's surplus was measured in order to evaluate the social benefit to be derived from expanding health insurance to the entire population. The most refined and correct way to measure a project's net benefit to society is to determine a change in the consumer's surplus. Benefits from introducing the health insurance program to the uninsured people can be classified into two elements. The first is the pricing-down effect(E1) which results from applying the insurance price system, which is lower than the actual price, to the uninsured patients. The second effect(E2) is a decrease in actual payment because an insured patient pays only a portion of the total medical bill(copayment). We collected medical price information from the data banks of 93 hospitals, and obtained information of medical utilization by referring to the results of other research and from data published by the Korean Medical Insurance Societies. The total net benefit was estimated as won214 billion, comprising the first effect(E1) of won57 billion and the second effect(E2) of won157 billion. The price elasticity of physician visits is less than that of hospital admissions; however, benefits from the increase in physician visits are greater than those from hospital admissions because there are considerably more of physician visits than hospital admissions. The sensitivity analysis also shows the conclusion that expansion of the health insurance program to the entire population would result in a positive net benefit. Therefore, we conclude that the National Health Insurance Program is socially desirable.
A Comparison Study of Pulmonary Tuberculosis Patients Between those with Previous History of Treatment and Those Without it before Registration to Health Center.
Han Joong Kim, Dong Chul Park
Korean J Prev Med. 1983;16(1):129-134.
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The records for the tuberculosis patients who discharged from the health center during 1982 in Kangwha county were analyzed in order to study the characteristics and the patterns of treatments for the pulmonary tuberculosis patients with the history of previous treatment before registration and also the relationship between the previous history of treatment and the outcome at the time of discharge from the health center. The major findings are as follows. 1. Those who have a history of previous treatment were 58, 22.5% of those 258 patients who were studied. 2. There is no difference in sex however the rate of previous history of treatment was higher among middle age group (20-59) than young and old age group (under 19 or over 60). 3. The rate of previous treatment was rather higher in those lived in remote area from Eup. 4. As for the relationship with occupation, students and civil servants who easily exposured to the public relations of government's tuberculosis control program experienced lower previous treatment before registration than farmers or unemployed. 5. A total of 62.1% were previously treated less than 6 months, 29.3% between 6 and 12 months, and only 8.6% more than 12 months before registration to health center. 6. The most common used anti-tuberculosis drugs were isoniazid and ethambutol but only 13.8% used government-standardized prescription and 69.0% used secondary drugs from its beginning. 7. There was no statistical difference between the previous history of treatment and the outcome at the time of discharge from the health center. However the longer the duration of treatment before registration was the lower the cure rate at health center was.
An Analysis of the Medical Aid Program on the Utilization Aspect in Rural Korea.
Han Joong Kim
Korean J Prev Med. 1978;11(1):41-48.
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To examine the result of the government Medical Aid Program which began in January, 1977 as a part of social security policy implementation, all the medical records of the clients and official statistics in the year were analyzed. The specific objectives this study pursues include the magnitudes and patterns of morbidity and utilization, and the characteristics of clients. One Korean rural area, Koje county was selected as the study area and subsequently all the clinics and hospitals assigned to work out the Aid Program are the subjects for the survey. A brief summary of the study results as follows: a. The clients of Koje county are 6.4% of the total population in the area, more than the average percentage of the clients in Korea. It reflects on low level of economic status of the residents of the area. b. The population structure of the clients indicates that the large proportions of young and old age group are overwhelming, while the middle age group share very small portions. 3c. The utilization rates for primary care are 2.0 persons, 11.6 visits and 22.6 treatment days per 100 persons per months. Annual hospitalization is rated as 13.7 cases and 164 days per 1,000 persons. The utilization rates are slightly lower than those expected rates during planning period but eventually become higher than those of general population in rural Korea. d. The factors which influence the utilization rates are identified with client group(low income vs indigent), age and sex. e. The utilization pattern for primary care demonstrates seasonal variation similar to the pattern of general rural population in the low income group, but none in the indigent group. f. The most common diseases revealed at the primary care clinics are the acute respiratory infection (26.9%), acute gastritis (10.8%), skin and subcutaneous infection (6.8%). The cases of acute conditions are outnumbered than the cases of chronic condition. g. The clinics, hospitals and other related health institutions are well cooperated in dealing health care services in their own capacities. Considering the above results Medical Aid Program generated satisfactory results at least in the utilization aspect.
Measuring Myun Health Worker's Performance by Time-Activity Approach.
Han Joong Kim, Moon Shik Kim
Korean J Prev Med. 1977;10(1):34-43.
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This study attempts to examine the performances of Myun Health Workers-the frontline workers in the Korean rural health care delivery system. The time-activity approach was mainly utilized as a measuring tool. This study was undertaken in September 1976 with 35 Myun Health Workers at the Kang Wha Country. The pretested time-activity approach sheets were filled out daily for one month by those Myun Health Workers themselves. Statistical means and variances of analysis were utilized for statistical method in comparing some activities and functions converged into time distribution. Findings: 1. The workers's average working hours derived in this study is 8 hours and 48 minutes per day, which takes half an hour longer than normal schedule. 2. They spend 56% working hour for direct services, in other words, the main function, 22% for supportive function, and 22% for other activities, the unrelated health services. 3. Considering the total working hours of main function, out-center activity is far more than in-center services with the ratio of 70% to 30% respectively, which proves, therefore, that the main activity of the workers is home visiting. 4. It takes 20 minutes purely for home visition and takes 14 minutes for transportation. 5. This research also indicates that such factors as characteristics of the health workers and myun influence in shaping the structures of the worker's function and activity: a. The workers whose working site is located is myun office spend 15% among total working hours in carring out official myun activities, which is incidentally unrelated to health services, while the health subcenter have no rooms for administrative jobs for myun office. b. The workers whose office is in health subcenter contribute much time in doing main function and those working in special project distribute more time in performing supportive function. c. The types of workers are another dominant factor to influence the components of worker's functions and activities. d. MPW II, whose function is reorganized by special project in 2 myuns shows different pattern of time distribution compared to the TB worker orFP worker in the ordinatry area. MPW II distributes their time evenly in performing MCH program, T.B. program, F.P. program and education activity, while the unipurpose workers engage in carring out only their dominant role. e. Another variables which involve th variation of the worker's activity can be illustrated with the variables like target population, size of myun and convenience for transportation, among which the latter two are remarkable factors in determining the time for out-center service.
Study of Medical Carein Health Subcenter.
Moon Shik Kim, Han Joong Kim, Young Key Kim, Il Soon Kim
Korean J Prev Med. 1976;9(1):109-116.
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Reorganization of myun health care service is one of the main issues in health care delivery in rural Korea. The fundamental, concept of the role and function of the myun health subcenter is that it is the basic unit of rural health care service and is to provide comprehensive health care service through the integration of curative and preventive services. The aim of this study is to analyze the patterns of curative activities in the myun health subcenter in terms of the most prevalent types of diseases, necessary diagnostic methods and required equipment, types of treatment, necessary drugs and materials, and finally the cost of curative services. The population on which this study was done was the 1596 patients who visited the two myun health subcenters (Sunwon Myun and Naega Myun) in Kang Hwa County, the area of the Yonsei University Community Health Teaching Project, during period from May 1, 1975 to June 10, 1976. For the patient's record in the clinic, problem oriented medical records were used. Decisions regarding the disease classification, the diagnostic methods used and selection of the most appropriate and adequate medical treatment were made by a group of three experienced physicians after reviewing the medical records which had been written by public physicians who were treating patients in the study area. The records were reviewed by resident staff members of the Department of Preventive Medicine, of Yonsei University College of Medicine. A brief summary of results of the study is as follow: 1. 29.9% of the patients who visited the clinics were ages between 0-4. No sex difference was observed among patients less than 20 years of age. However, among patients over 20 years old, females predominated. Thus it is evident that the majority of patients were either children or mothers and grandmothers. 2. The distance from the individual villages to the myun health subcenter was one of important factors in determining the ratio of clinic visits. However, other factors such as the activities of the health workers also affected the rates substantially. 3. The most common 25 diseases comprised 90.2% of all the diseases recorded. Acute respiratory infection (25.5), skin (12.7%), diarrheal diseases (6.8%), neuralgia and back pain (4.9%) and all other injuries (3.9%) were the five most common diseases. 4. Of all the diseases diagnosed and treated, 9.2% required simple laboratory tests for diagnosis, 6.5% required X-ray examination, and altogether 13.6% required either laboratory test of X-ray examination. 5. Treatment and management of 42.0% of the cases could be accomplished with simple, inexpensive drugs, 12.8% required the use of more expensive drugs (mostly antibiotics) and injections were required in 19.7% of the cases. Minor surgery and referral were necessary in 5% of the cases. 6. The cost for diagnosis and treatment was estimated with a standard which was set by general concensus. The average cost of diagnosis was 144 per case and the cost of treatment was 726 per case. The total average cost per visit was 870.

JPMPH : Journal of Preventive Medicine and Public Health