Cases of Dispute and Pending Claims in Hospitals in the Era of National Health Insurance

Background: Indonesia began to implement a National Health Insurance System based on the National Social Security System in 2014 with the support of government regulations which states that Indonesia requires every citizen to have access to comprehensive and quality health services so that can continue their life through the National Health Insurance. Pending and dispute claims are problems that often occur in the era of national health insurance that can affect hospital budget allocation and planning policies, increasing the high cost burden for hospitals which will affect the quality of health services provided. The purpose of this study was to determine pending cases and dispute claims in hospitals in the Era of National Health Insurance.Methods: The study used a descriptive method with a qualitative approach. The data collection technique used is the observation method, namely directly to the e-claim file at several hospitals. 15 e-claim files taken in total from April – July 2021.Results: Obtained 13 cases of pending claims and 2 cases of dispute claims. Cases pending claims are caused by not complying with the code with evidence or resources, not in accordance with medical clinical practice guidelines and the rules of the health insurance provider.Conclusions: In coding, it is necessary to match the theory on the ICD-10, update the ICD-10. It is necessary to understand the rules and provisions made by the insurer and the related guidelines and rules. Please be aware of every latest code update.

Severe Hypoglycemia Increases Dementia Risk and Related Mortality: A Nationwide, Population-Based Cohort Study

Context There are few studies focused on the relationship between hypoglycemia and new-onset dementia in patients with type 2 diabetes and no study regarding mortality of dementia after hypoglycemia. Objective We investigated the effect of severe hypoglycemia on dementia subtypes and its relation to overall mortality in patients with type 2 diabetes. Methods We evaluated incident dementia, including Alzheimer disease and vascular dementia, among health checkup participants aged 40 years or older in the National Health Insurance System in Korea from January 2009 to December 2015. Episodes of severe hypoglycemia were examined for 3 years before the date of the health checkup. Results Among 2 032 689 participants (1 172 271 men, 860 418 women), 14 443 (0.7%) experienced severe hypoglycemia, during a mean follow-up period of 6.9 ± 1.7 years. Individuals in the severe hypoglycemia group were more likely to be diagnosed with dementia compared to individuals without severe hypoglycemia (23.3% vs 7.3%; P < .001) and the overall incidence of Alzheimer disease was higher than vascular dementia. Dementia risk rose with increasing number of severe hypoglycemic episodes (1 episode [hazard ratio (HR) = 1.54; 95% CI, 1.48-1.60], 2 or more episodes [HR = 1.80; 95% CI, 1.66-1.94]). Overall mortality was higher in participants with dementia, but without severe hypoglycemia (HR = 2.03; 95% CI, 1.96-2.10) and severe hypoglycemia, but without dementia (HR = 4.24; 95% CI, 4.29-4.40), and risk of death was highest in those with both severe hypoglycemia and dementia (HR = 5.08; 95% CI, 4.83-5.35). Conclusion Severe hypoglycemia is associated with dementia, especially Alzheimer disease and mortality; together, they have an additive effect on overall mortality.

Chronic Kidney Disease in a Large National Human Immunodeficiency Virus Treatment Program

Introduction: Tenofovir disoproxil fumarate (TDF) is associated with a risk of chronic kidney disease (CKD), especially when used with protease inhibitors or in Asian populations. Data from the Thai national health insurance system were used to assess the incidence of CKD in patients receiving antiretroviral therapy (ART) in real-world practice. Materials and methods We analyzed data from patients who initiated one of the following first-line ART regimens: (i) zidovudine+lamivudine+nevirapine (AZT+3TC+NVP); (ii) zidovudine+lamivudine+efavirenz (AZT+3TC+EFV); (iii) tenofovir+lamivudine+nevirapine (TDF+3TC+NVP); (iv) tenofovir+lamivudine/emtricitabine+efavirenz (TDF+3TC/FTC+EFV); and (v) tenofovir+lamivudine+lopinavir/ritonavir (TDF+3TC+LPV/r). CKD was defined as glomerular filtration rate <60 mL/min/1.73 m2 for >3 months, or a confirmed 2010 WHO diagnosis (ICD-10 code N183, N184, or N185). Death competing risks survival regression models were used for the analysis. Results Among 27,313 participants, median age 36.8 years, body mass index 20.4 kg/m2, and absolute CD4 cell count 146 cells/mm3, followed for a median 2.3 years, 245 patients (0.9%) were diagnosed CKD (incidence 3.2 per 1,000 patient-years of follow-up; 95% confidence interval [CI] 2.8-3.6). Compared with patients receiving AZT+3TC+NVP, the risk of CKD measured by adjusted sub-distribution hazard ratio (aSHR) was higher in patients on TDF+3TC+LPV/r (6.5, 95% CI 3.9-11.1), on TDF+3TC+NVP (3.8, 95% CI 2.3-6.0) and on TDF+3TC/FTC+EFV (1.6, 95% CI 1.2-2.3). Among patients receiving TDF, compared with those receiving TDF+3TC/FTC+EFV, the risk was higher on TDF+3TC+LPV/r (4.0, 95%CI 2.3-6.8) on TDF+3TC+NVP (2.3, 95%CI 1.4-3.6) . Conclusions This real-world study suggest that the role of TDF in increasing the risk of CKD, especially when combined with LPV/r or NVP.

The Development of a Nationwide, Multicenter Electronic Database for Spinal Instrumentation Surgery in Japan: Japanese Spinal Instrumentation Society Database (JSIS-DB)

(1) Background: Despite the number of complicated and expensive spine surgery procedures maintained by the national health insurance system in Japan, until now there has been no large-scale multicenter clinical database for this field to understand and improve healthcare expenditure and treatment outcomes. The purpose of this report is to announce the establishment and methodology of a nationwide registry system for spinal instrumentation surgeries by the Japanese Spinal Instrumentation Society (JSIS), and to report the progress over the first 1.5 years of this database’s operation. (2) Methods: The JSIS recently produced an online database with an electronic server. The collected information included patient background, surgery information, and early complications of primary and revision cases. Analysis included data from February 2018, when registration began, to August 2019. (3) Results: As of August 2019, 73 facilities have completed the required paperwork to start, and 55 facilities have registered cases. Of the total 5456 registered cases, 4852 were valid and 2511 were completed. (4) Conclusions: JSIS-DB, the nationwide web-based registry system for spinal instrumentation surgery in Japan, was launched for the purpose of research, healthcare policy regulation, and improved patient care, and its methodology and progress in the first 1.5 years are reported in this study.

Financial Burden and Health-seeking Behaviors Related to Chronic Diseases Under the National Health Insurance Scheme in Bolikhamxay Province, Lao PDR: A Cross-sectional Study

BackgroundFinancial protection is a key dimension of universal health coverage. In 2016, Lao PDR implemented a National Health Insurance system covering the entire population of certain provinces. This cross-sectional study investigated the health-seeking behavior and financial burden of households, including those with chronic patients, post coverage. MethodThe study was conducted in Bolikhamxay province from January 15 to February 13, 2019. In total, 487 households, selected via stratified random sampling, were surveyed, and questionnaire-based interviews were conducted. Health care service utilization and financial burden were examined.ResultsA total of 370 households had at least one member with some type of self-reported health problem within the last 3 months prior to the interview, while 170 had at least one member with a chronic condition. More than 75% of the households accessed a health facility when a member experienced health problems. The prevalence of catastrophic health expenditure (health expenditure/income between 20% and 40%) was 25.1% (threshold of 20%) and 16.2% (threshold of 40%). Through logistic regression, we found that the major factors determining financial catastrophes owing to health problems were household members with chronic illness, hospitalization, household poverty status, family size (both 20% and 40% thresholds), visiting a private facility (20% threshold), and distance from the province to the referral hospital (40% threshold).ConclusionsThe National Health Insurance system has positively impacted households’ access to health facilities. However, catastrophic health expenditure remains high, especially among chronic patients. Facilities under the National Health Insurance should be strengthened to provide more services, including care for chronic conditions.

PEDT-9 A study of NovoTTF-100A to expand the regulatory indication for childhood glioblastoma through a pediatric clinical trial based on the Advanced Medical Care system

Background: Tumor-treating fields (TTF) are alternating electric fields applied continuously to the brain by attaching 2-pair arrays on the scalp. Although TTF therapy has demonstrated efficacy against supratentorial glioblastoma (GBM) in adults, its safety and efficacy in children have not been confirmed. In Japan, off-label use of medical devices is almost impossible because the national health insurance system does not cover the cost of off-label use of drugs and medical devices. Therefore, TTF therapy cannot be applied to the treatment of pediatric GBM. [Objectives] The investigator-initiated clinical trial aims to expand regulatory approval of TTF therapy for pediatric GBM treatment based on safety and exploratory efficacy data. Methods: Patients aging between 5 and 17 years with histopathological diagnosis of GBM (either newly diagnosed or first-recurrence), which located in the supratentorial region would be included. All the patients will receive TTF therapy for 28 days per course for up to 26 courses until the end-of-therapy criteria are met. The primary endpoint is the adverse event rate with causality. The secondary endpoints include various time-to-event measures and QoL. In total ten patients will be enrolled. Current Status: Discussions with the Pharmaceuticals and Medical Devices Agency (PMDA) led to a tentative consensus that the accumulated data on the efficacy of NovoTTF-100A for adult GBM may be extrapolatable to pediatric GBM if the trial is able to demonstrate efficacy equivalent to that found in previous, adult studies. On the other hand, the combination of the pediatric safety data gathered in this trial and the findings of international studies, including clinical trials and post-marketing surveillance studies, may expedite approval of the device for pediatric GBM treatment. The trial started patient enrollment in April, 2021 with the supervision of the Advanced Medical Care administration system and is currently awaiting the first eligible patient.

Clinical Application of Automated Breast Ultrasound

Automatic breast ultrasound (ABUS) has been developed to compensate for the shortcomings of hand-held ultrasound (HHUS) and is mainly used for breast cancer screening purposes in women with dense breasts. Since 2021, ABUS has been covered by the Korean National Health Insurance System. It is important to scan the entire breast on ABUS and to identify the poor-quality images requiring re-scanning. In addition, a general understanding of the unique ABUS display mode, distinguishing benign from malignant lesions, the diagnostic performance of breast cancer screening, and the application of computer-aided detection/diagnosis systems is necessary to use ABUS efficiently. This review explores the acquisition method, image quality, and image characteristics of ABUS to improve general understanding of this procedure and its advantages over HHUS, so that ABUS can be applied efficiently in clinical practice.

Blood pressure variability and the risk of fracture: a nationwide cohort study

Context Although blood pressure variability (BPV) is associated with various health outcomes, only one study suggested that BPV is correlated with hip fractures. As cardiovascular disease and fractures share similar pathophysiology, there might be a link between BPV and fractures. Objective To investigate the association between BPV and the incident fractures. Design Retrospective cohort study. Setting Population-based, using the Korean National Health Insurance System database. Patients or Other Participants A total of 3,256,070 participants aged 50 and above who participated in ≥3 health examinations within the previous five years, including the index year (2009-2010), were included. Outcome data was obtained through the end of 2016. Exposure BPV was calculated using variability independent of the mean. High variability was defined as the highest quartile of variability. Main Outcome Measures Newly diagnosed fractures. Results During the median follow-up of 7.0 years, there were 337,045 cases of any fracture (10.4%). After adjusting for age, sex, income, lifestyle factors, and comorbidities, a higher risk of fracture was observed with higher quartiles of BPV than the lowest quartile group: the adjusted hazard ratios (95% confidence intervals) for incident any fracture were 1.07 (1.06–1.08) in the higher quartile of systolic BPV, 1.06 (1.05–1.07) in that of diastolic BPV, and 1.07 (1.06–1.08) in that of both systolic and diastolic BPV. Consistent results were noted for vertebral fractures and hip fractures, as well as in various subgroup analyses. Conclusions A positive association was noted between higher BPV and fracture incidence. BPV is an independent predictor for developing fracture.