Comparative Analysis on the Characteristics of High Cost Medical Users between the Health Insurance and Medical Assistance Program

Kang, Sunny; Moon, Ok-Ryun

Journal of Korean Society Quality Assurance Health Care 1996;2(2): 112.
Published online April 30, 1996.

고액진료비 환자의 특성 비교분석 - 의료보험과 의료보호환자를 중심으로 -

강선희, 문옥륜

서울대학교 보건대학원

Comparative Analysis on the Characteristics of High Cost Medical Users between the Health Insurance and Medical Assistance Program

Sunny Kang, Ok-Ryun Moon

School of Public Health, Seoul National University

Abstract

Background
A small number of high cost patients usually spend a larger proportion of scarce health resources. Aged, long-term care and readmitted patients usually belong to these high cost patient group. Among others, long length of stay and readmission can be reduced by checking its cause, and these are the areas needed most of quality improvement activity. Characteristics of high cost medical users between health insurance program and medical assistance program were reviewed.
Methods
The inpatient claims of health insurance and medical assistance program were analyzed. Patients were divided by 6 groups; long-term, mid-term, short-term, readmitted, cancer and aged. We defined high cost patients as those who had spent one and half million won and over per 6 months. Characteristics of high cost patients for each group were reviewed.
Results
medical assistance patients used much more resources than the insured members in the average hospital cost per case but less in daily hospital cost. The former had a longer length of stay and had much heavier diseases. Major diseases of both group were cancer, diseases of circulatory system and chronic degenerative diseases. Gallstone and schizophrenia were more in the insured program. However, pulmonary tuberculosis, asthma were more common among the medical assistance patients. Early readmission before 2 weeks were 28-30% of the total readmission. Readmission rate in the malignat neoplasm and renal failure were 80% and more. Q.A program should be installed to prevent unnecessary readmissions.
Conclusion
Almost 30% of early readmissions and admissions due to complications and long length of stay should be reviewed carefully to keep cost down and to enhance the quality of hospital care.

Key words high cost medical patients;health insurance;medical assistance program;early readmission;quality assurance;