우리나라 일차의료에서 외래의료비의 결정요인
Determinants of outpatient cost in primary care setting in korea
일차의료 지불제도 위험도 보정;
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Backgrounds Primary health care in Korea is difficult to clearly define its function and role. And primary care services are lack of core value of primary health such as comprehensiveness, coordinations and longitudinality. Payments system of health insurance are strongly related these weakness of primary care. Payment system reform is required with a various related policy and the calculation of annual expenses per patient in primary care may contribute more comprehensive and bundled payment methods. Objectives The purpose of this study is to set up a range of primary health care in Korea and determinants of health care in primary care. Firstly this study define a range of primary health care in Korea through analysis of patient patterns. Secondly determinants of annual expense of per patient within range of primary care will be presented using risk adjusted methods. Methods To set the range of primary care medical subjects were analyzed according to disease distribution using NHI(National health insurance) claims data. Patterns of disease in primary care is low severity and high proportion of chronic disease and mild disease. So through eight kinds of tools patterns of disease are analysed by speciality. Determinants of primary care medical expenditure are analysed using 10% sample data extracted from the NHI claims. To determine related factors three categories of variables are included in regression model. Three categories are demographics, comorbidity, prior healthcare utilization. Comorbidity factors are calculated by four methods and prior healthcare utilization are composed of total expenses and visit numbers of last year. Determinants of primary healthcare expenses are analyzed by age group, expenses levels and income level. Results According to results of cluster and primary components analysis, specialitis of clinics are divided into five kinds of groups. Among the groups, four specialities(family medicine, general physicians, cardiac surgery, general surgeon) have characteristics of primary care, composed high chronic and mild disease. In regression model for determinants of outpatients costs, R square value are about 35%. Prior healthcare utilizations are the largest contributions to model explanation and comorbidity are about one fourth of total explanations. There was a clear difference according to age groups, comorbidity and level of total costs. In most of models, 19 non communicable disease categories present the highest R square value compared to other risk adjustment tools. Conclusions This study empirically set the range of primary care and this evidence will be basic statistics for future discussion of primary health care. Also for a more comprehensive payment system, health care costs per patient in primary healthcare and it's determinants are presented.