Development of a Claim Review and Payment Model Utilizing Diagnosis Related Groups under the Korean Health Insurance

1993 ◽  
Vol 6 (1) ◽  
pp. 2-11 ◽  
Author(s):  
Young Soo Shin ◽  
Yong Kwon Yeom ◽  
Hark Hwang
Keyword(s):  
Health Insurance ◽  
Review Process ◽  
Diagnosis Related Groups ◽  
Empirical Test ◽  
Case Mix ◽  
Fee For Service ◽  
Payment Model ◽  
Proposed Model ◽  
The Us ◽  
Case Basis

This paper describes the development of a claim review and payment model utilizing the diagnosis related groups (DRGs) for the fee for service-based payment system of the Korean health insurance. The present review process, which examines all claims manually on a case-by-case basis, has been considered to be inefficient, costly, and time-consuming. Differences in case mix among hospitals are controlled in the proposed model using the Korean DRGs. They were developed by modifying the US-DRG system. An empirical test of the model indicated that it can enhance the efficiency as well as the credibility and objectivity of the claim review. Furthermore, it is expected that it can contribute effectively to medical cost containments and to optimal practice pattern of hospitals by establishing a useful mechanism in monitoring the performance of hospitals. However, the performance of this model needs to be upgraded by refining the Korean DRGs which play a key role in the model.

scholarly journals Principal-agent problems in implementation of Ghana’s health insurance scheme

2018 ◽  
Vol 11 (2) ◽  
pp. 59 ◽  
Author(s):  
Daniel Dramani Kipo-Sunyehzi
Keyword(s):  
Health Insurance ◽  
Health Service ◽  
Health Services ◽  
Service Providers ◽  
Diagnosis Related Groups ◽  
Principal Agent ◽  
Fee For Service ◽  
The Public ◽  
Health Service Providers ◽  
Profit Maximisation

<p>Principal-agent relationship exists between health service providers and their authority and clients. It asserts that health service providers as ‘imperfect agents’ of the authority and clients will take actions that aim to maximise profits at the expense of authority and clients (principal). The situation is possible when reimbursement is based on fee-for-service or a diagnosis-related groups. It looks at relationships between health service providers as agents and health insurance authority, and clients as principals in areas of provision of health services, supply of drugs, medicines and reimbursement. Results showed the private health service providers prescribed more drugs and medicines for clients towards profit maximisation (agency) than their public counterparts. Also, it was found that the public health service providers continued to provide health services and drugs despite health insurance authority indebtedness to them exhibiting more stewardship towards health insurance authority. It recommends strict regulations in tariffs/vetting claims and prompt reimbursement.</p>

scholarly journals Why Is Collaborative Apparel Consumption Gaining Popularity? An Empirical Study of US Gen Z Consumers

2021 ◽  
Vol 13 (15) ◽  
pp. 8360
Author(s):  
Lindsay McCoy ◽  
Yuan-Ting Wang ◽  
Ting Chi
Keyword(s):  
Explanatory Power ◽  
Intention To Use ◽  
Fashion Leadership ◽  
Mediating Role ◽  
Need For Uniqueness ◽  
Proposed Model ◽  
The Us ◽  
Multiple Regression Method ◽  
Perceived Consumer Effectiveness ◽  
Sustainability Movement

Apparel rental, also known as collaborative apparel consumption, has created an innovative and popular business model, providing consumers with the ability to focus on using their products instead of ownership. Recent surveys show that sustainability is driving demand and customer loyalty in the US. Among all generations, Gen Z consumers lead the way. To better understand the emerging popularity of apparel rental services among Gen Z consumers who are becoming a major driving force for retail growth and the sustainability movement, this study aimed to identify the factors significantly influencing Gen Z consumers’ intention to use apparel rental services; 362 eligible responses were gathered via a questionnaire survey. The psychometric properties of the proposed model were examined, and the multiple regression method was applied to test the hypotheses. Attitude, subject norms, perceived consumer effectiveness, past environmental behavior, and fashion leadership significantly affected Gen Z consumers’ intentions to use apparel rental services. Attitude plays a mediating role between Gen Z consumers’ environmental knowledge, fashion leadership, need for uniqueness, and their intention to use apparel rental services. The proposed research model exhibited good explanatory power, accounting for 58.6% of the variance in Gen Z consumers’ use intention toward apparel rental services.

scholarly journals The convergence of racial and income disparities in health insurance coverage in the United States

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
De-Chih Lee ◽  
Hailun Liang ◽  
Leiyu Shi
Keyword(s):  
Health Insurance ◽  
Low Income ◽  
Insurance Coverage ◽  
Health Insurance Coverage ◽  
The United States ◽  
Combined Effect ◽  
Medical Expenditure ◽  
The Us ◽  
Race Ethnicity ◽  
Vulnerability Measure

Abstract Objective This study applied the vulnerability framework and examined the combined effect of race and income on health insurance coverage in the US. Data source The household component of the US Medical Expenditure Panel Survey (MEPS-HC) of 2017 was used for the study. Study design Logistic regression models were used to estimate the associations between insurance coverage status and vulnerability measure, comparing insured with uninsured or insured for part of the year, insured for part of the year only, and uninsured only, respectively. Data collection/extraction methods We constructed a vulnerability measure that reflects the convergence of predisposing (race/ethnicity), enabling (income), and need (self-perceived health status) attributes of risk. Principal findings While income was a significant predictor of health insurance coverage (a difference of 6.1–7.2% between high- and low-income Americans), race/ethnicity was independently associated with lack of insurance. The combined effect of income and race on insurance coverage was devastating as low-income minorities with bad health had 68% less odds of being insured than high-income Whites with good health. Conclusion Results of the study could assist policymakers in targeting limited resources on subpopulations likely most in need of assistance for insurance coverage. Policymakers should target insurance coverage for the most vulnerable subpopulation, i.e., those who have low income and poor health as well as are racial/ethnic minorities.

A clinical update on managed care implications for Australian psychiatric practice

2021 ◽  
pp. 103985622110300
Author(s):  
Jeffrey CL Looi ◽  
Stephen R Kisely ◽  
Tarun Bastiampillai ◽  
William Pring ◽  
Stephen Allison
Keyword(s):  
Health Insurance ◽  
Managed Care ◽  
Private Health Insurance ◽  
Psychiatric Treatment ◽  
Patient Choice ◽  
Insurance Sector ◽  
Cost Cutting ◽  
Appropriate Treatment ◽  
The Us ◽  
Limit Access

Objective: To provide a clinical update on private health insurance in Australia and outline developments in US-style managed care that are likely to affect psychiatric and other specialist healthcare. We explain aspects of the US health system, which has resulted in a powerful and profitable private health insurance sector, and one of the most expensive and inefficient health systems in the world, with limited patient choice in psychiatric treatment. Conclusions: Australian psychiatrists should be aware of changes to private health insurance that emphasise aspects of managed care such as selective contracting, cost-cutting or capitation of services. These approaches may limit access to private hospital care and diminish the autonomy of patients and practitioners in choosing the most appropriate treatment. Australian patients, carers and practitioners need to be informed about the potential impact of private managed care on patient-centred evidence-based treatment.

scholarly journals Schockraum- und Schwerverletztenversorgung als „Verlustgeschäft“

2020 ◽  
Author(s):  
Thomas Gross ◽  
Felix Amsler
Keyword(s):  
Injury Severity Score ◽  
Severity Score ◽  
Injury Severity ◽  
Diagnosis Related Groups ◽  
Case Mix ◽  
Multivariate Analyse ◽  
New Injury Severity Score ◽  
Case Mix Index

Zusammenfassung Hintergrund Es galt herauszufinden, wie kostendeckend die Versorgung potenziell Schwerverletzter in einem Schweizer Traumazentrum ist, und inwieweit Spitalgewinne bzw. -verluste mit patientenbezogenen Unfall‑, Behandlungs- oder Outcome-Daten korrelieren. Methodik Analyse aller 2018 im Schockraum (SR) bzw. mit Verletzungsschwere New Injury Severity Score (NISS) ≥8 notfallmäßig stationär behandelter Patienten eines Schwerverletztenzentrums der Schweiz (uni- und multivariate Analyse; p < 0,05). Ergebnisse Für das Studienkollektiv (n = 513; Ø NISS = 18) resultierte gemäß Spitalkostenträgerrechnung ein Defizit von 1,8 Mio. CHF. Bei einem Gesamtdeckungsgrad von 86 % waren 66 % aller Fälle defizitär (71 % der Allgemein- vs. 42 % der Zusatzversicherten; p < 0,001). Im Mittel betrug das Defizit 3493.- pro Patient (allg. Versicherte, Verlust 4545.-, Zusatzversicherte, Gewinn 1318.-; p < 0,001). Auch „in“- und „underlier“ waren in 63 % defizitär. SR-Fälle machten häufiger Verlust als Nicht-SR-Fälle (73 vs. 58 %; p = 0,002) wie auch Traumatologie- vs. Neurochirurgiefälle (72 vs. 55 %; p < 0,001). In der multivariaten Analyse ließen sich 43 % der Varianz erhaltener Erlöse mit den untersuchten Variablen erklären. Hingegen war der ermittelte Deckungsgrad nur zu 11 % (korr. R2) durch die Variablen SR, chirurgisches Fachgebiet, Intensivaufenthalt, Thoraxverletzungsstärke und Spitalletalität zu beschreiben. Case-Mix-Index gemäß aktuellen Diagnosis Related Groups (DRG) und Versicherungsklasse addierten weitere 13 % zu insgesamt 24 % erklärter Varianz. Diskussion Die notfallmäßige Versorgung potenziell Schwerverletzter an einem Schweizer Traumazentrum erweist sich nur in einem Drittel der Fälle als zumindest kostendeckend, dies v. a. bei Zusatzversicherten, Patienten mit einem hohen Case-Mix-Index oder einer IPS- bzw. kombinierten Polytrauma- und Schädel-Hirn-Trauma-DRG-Abrechnungsmöglichkeit.

scholarly journals Healthcare Access and Utilization among Korean Americans: The Mediating Role of English Use and Proficiency

2016 ◽  
Vol 4 (1) ◽  
pp. 83 ◽  
Author(s):  
Jiang Li ◽  
Annette E. Maxwell ◽  
Beth A. Glenn ◽  
Alison K. Herrmann ◽  
L Cindy Chang ◽  
...  
Keyword(s):  
Health Insurance ◽  
Length Of Stay ◽  
Health Services ◽  
Insurance Coverage ◽  
Korean Americans ◽  
Usual Source Of Care ◽  
Mediating Role ◽  
Usual Source ◽  
The Us ◽  
Source Of Care

The literature suggests that Korean Americans underutilize health services. Cultural factors and language barriers appear to influence this pattern of low utilization but studies on the relationships among length of stay in the US, English use and proficiency, and utilization of health services among Korean Americans have yielded inconsistent results. This study examines whether English language use and proficiency plays a mediating role in the relationships between length of stay in the US and health insurance coverage, access to and use of care. Structural equation modeling was used for mediation analysis with multiple dependent variables among Korean Americans (N= 555) using baseline data from a large trial designed to increase Hepatitis B testing. The results show 36% of the total effect of proportion of lifetime in the US on having health insurance was significantly mediated by English use and proficiency (indirect effect =0.166, SE= 0.07, p<.05; direct effect=0.296, SE= 0.13, p<.05). Proportion of lifetime in the US was not associated with usual source of care and health service utilization. Instead, health care utilization was primarily driven by having health insurance and a usual source of care, further underscoring the importance of these factors. A focus on increasing English use and proficiency and insurance coverage among older, female, less educated Korean Americans has the potential to mitigate health disparities associated with reduced access to health services in this population.

National estimates of case‐mix, mortality, and economic outcomes among inpatient HIV/AIDS mono‐infection and hepatitis C co‐infection cases in the US

2018 ◽  
Vol 25 (5) ◽  
pp. 806-821
Author(s):  
Timothy Pham ◽  
R. Chris Rathbun ◽  
Shellie Keast ◽  
Nancy Nesser ◽  
Kevin Farmer ◽  
...  
Keyword(s):  
Hepatitis C ◽  
Economic Outcomes ◽  
Case Mix ◽  
The Us ◽  
National Estimates ◽  
Hiv Aids

SEC permits all issuers to submit confidential draft registration statements

2017 ◽  
Vol 18 (4) ◽  
pp. 16-21
Author(s):  
Andrew Brady ◽  
Brian Breheny ◽  
Michelle Gasaway ◽  
Stacy Kanter ◽  
Michael Zeidel ◽  
...  
Keyword(s):  
Corporate Finance ◽  
Design Methodology ◽  
Review Process ◽  
Going Public ◽  
Content Type ◽  
Submission Process ◽  
The Us ◽  
Practical Guidance ◽  
Jobs Act ◽  
A Company

Purpose To explain the US Securities and Exchange Commission’s (SEC’s) June 29, 2017 announcement (as updated August 17, 2017) that the staff of its Division of Corporation Finance will accept draft registration statement submissions from all companies for nonpublic review, thereby expanding a popular benefit previously available only to emerging growth companies (ECGs) under the JOBS Act and, in limited circumstances, to certain foreign private issuers under historical Staff practices. Design/methodology/approach Explains the rationale and limitations of the new policy, the existing confidential submission process, the expanded class of issuers and transactions that now qualifies for the nonpublic review process, and content and staff processing details. Findings Recognizing that the confidential submission process for EGCs proved highly popular and quickly became standard practice for eligible companies seeking to conduct an IPO, the SEC has made the nonpublic review process available to an expanded class of issuers and transactions. The expanded confidential submission process for IPOs addresses some of the typical concerns associated with engaging in the IPO process by giving a company more time and flexibility to determine whether it actually will be able to achieve the benefits of going public before it incurs the burdens and expenses of doing so. Originality/value Practical guidance from experienced securities and corporate finance lawyers.

scholarly journals The Benefits of Gamification in the English Learning Context

2020 ◽  
Vol 7 (1) ◽  
pp. 32-47
Author(s):  
Eka Fajar Rahmani
Keyword(s):  
Qualitative Research ◽  
Review Process ◽  
English Education ◽  
English Learning ◽  
Learning Context ◽  
English Class ◽  
Positive Attitudes ◽  
The Us ◽  
Context Of Learning ◽  
Positive Results

ABSTRACTThis study aims at displaying the results of reviewing research-based articles about gamification in the context of learning English. The concept of games has changed from a self-entertainment into an edutainment through adjustments and modifications. This notion is adapted by teachers in big countries such as Poland, China, and the US to enhance their English class with surprisingly ensuing positive results (Rothwell & Shaffer, 2019). These results have triggered the writer to find out more about the benefits of gamification and to conduct qualitative research through the review process. The writer collected and analyzed thirteen relevant articles from journals and websites. The results indicated that gamification indeed brought benefits to students. The foremost results included motivation improvement, promoting positive attitudes and better performances, fostering 21st-century skills and better cognitive achievements, encouraging social interaction and independencies, and improving competitiveness among students during the learning process.ABSTRAKPenelitian ini bertujuan untuk memaparkan hasil dari telaah artikel berbasis riset tentang gamifikasi pada konteks pembelajaran Bahasa Inggris. Konsep permainan telah berubah dari hiburan mandiri menjadi edutainment melalui penyesuaian dan modifikasi. Konsep ini, terutama permainan online, diadaptasi oleh para guru di negara-negara besar seperti Polandia, China, dan US untuk meningkatkan aktifitas kelas Bahasa Inggris mereka dengan yang hasil positif yang mengejutkan (Rothwell & Shaffer, 2019). Hasil ini menjadi motivasi penulis untuk menggali lebih dalam tentang manfaat gamifikasi dalam pembelajaran Bahasa Inggris sehingga penulis melakukan penelitian kualitatif melalui proses review. Penulis telah mengumpulkan dan menganalisa tiga belas artikel yang relevan dari jurnal dan situs web. Hasil analisa menunjukkan bahwa gamifikasi memang bermanfaat bagi siswa. Manfaat yang paling utama yaitu meningkatkan motivasi dan penampilan yang baik, mengembangkan keterampilan Abad 21, mendorong interaksi social dan kebebasan, serta meningkatkan daya saing antar siswa selama pembelajaran. How to Cite: Rahmani, E.F. (2020). The Benefits of Gamification in the English Learning Context. IJEE (Indonesian Journal of English Education), 7(1), 32-47. doi:10.15408/ijee.v7i1.17054

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