Does long-term care insurance reduce burden of medical costs? A retrospective elderly cohort study

Dept. of Public Health/박사Background: The government has implemented the long-term care insurance (LTCI) to support the healthcare needs of the elderly. The purpose of this service is to reduce unnecessary inpatient medical utilization and reduce the burden of excessive medical costs through a substitution effect. Thus, this study aims to examine whether LTCI reduces medical utilization and the burden of medical costs of beneficiaries who have received the service for at least three consecutive years. Materials and Methods: We utilized the elderly cohort database (DB) of the National Health Insurance Service during 2005-2013. The subjects are 3,029 beneficiaries who received consecutive LTCI services. In addition, we performed a 1:3 case-control match on the propensity score to select a comparison group and the final subjects were 12,116 people, including 9,087 who formed the control group. The dependent variables were semiannually measured medical utilizations (inpatient, outpatient, and drug prescription) and the burden of medical costs at the individual level, and the independent variable is an interaction term (benefit*period) through difference-in-difference analysis. This study adjusted factors that affect medical utilization and then applied the method of generalized estimating equations (GEE) to the data. Results: After applying multivariable models, this study indicates that the number of hospitalizations of beneficiaries significantly decreased compared to non-beneficiaries (adjusted ratio: 0.95; 95% confidence interval [CI], 0.95 to 0.96). Similarly, length-of-stay (LOS) of beneficiaries also shows significant reduction compared to non-beneficiaries (adjusted ratio: 0.76; 95% C.I., 0.73 to 0.79). The number of hospitalizations (adjusted ratio: 0.87; 95% C.I., 0.74 to 0.98) and LOS (adjusted ratio: 0.36; 95% C.I., 0.14 to 0.87) of beneficiaries decreased substantially compared to non-beneficiaries’ stay in long-term care hospitals, among hospital types. The number of outpatient visits and receipt of drug prescriptions of beneficiaries and non-beneficiaries increased marginally. The burden of medical costs of beneficiaries reduced considerably compared to non-beneficiaries (adjusted ratio: 0.80; 95% C.I., 0.77 to 0.83). However, the burden of support costs (medical cost + long-term care cost) in beneficiaries increased significantly compared to non-beneficiaries (adjusted ratio: 1.18; 95% C.I., 1.15 to 1.21). Conclusions: Long-term care insurance has led to a significant decline in the utilization rates of inpatient service. The government needs to arrange appropriate criteria, an efficient link system, and a trained specialist who can coordinate inpatient care for patients in an LTCI hospital or facility. The study results also show that the burden of medical costs for LTCI beneficiaries reduced significantly compared to non-beneficiaries, despite the rise in medical costs in the elderly. The positive effect of LTCI supports continuous implementation and expansion of the LTCI service for non-beneficiaries who need care assistance. 서론: 정부는 노인의 장기요양을 지원하기 위해 장기요양보험제도를 시행하였다. 이러한 장기요양보험제도의 도입은 대체효과를 통해 수급자들의 불필요한 입원이용을 감소시키고 과도한 의료비 부담을 낮출 수 있을 것이다. 따라서 이 연구는 장기요양보험제도가 최소 3년 이상 장기요양서비스를 받았던 수급자들의 의료이용과 의료비 부담을 감소시켰는지를 관찰하고자 한다. 자료 및 방법: 이 연구는 국민건강보험공단에서 제공하는 노인 코호트 자료 중 2005-2013년 자료를 활용하였다. 연구대상은 최소 3년 이상 연속적으로 장기요양서비스를 받은 수급자 3,029명이다. 또한 이 연구에서는 비교군을 선정하기 위해 성향점수를 통한 1:3 매칭방법을 사용하여 대조군 9,087명을 추출하였으며 따라서 이 연구의 최종 연구대상은 총 12,116명이었다. 이 연구의 종속변수는 개인단위의 반기별 의료이용(입원, 외래, 약제처방)과 의료비 부담수준이었으며 독립변수는 이중차이분석 방법을 통한 교호작용 항(Interaction term)이었다. 이 연구는 의료이용에 영향을 미칠 수 있는 요인들을 통제하였으며 통계분석방법으로는 일반화추정방정식 (GEE) 방법을 이용하였다. 결과: 다른 요인들을 통제한 다변량 분석에서 장기요양보험 수급자의 입원횟수와 재원일수가 각각 통계적으로 유의하게 감소하였다. 병원유형 중 요양병원에 입원한 환자의 입원횟수와 재원일수가 크게 감소하였다. 외래방문횟수와 처방약 수령횟수는 수급자와 비수급자 모두에서 약간 증가하였다. 수급자의 의료비 부담은 비수급자에 비해 통계적으로 유의하게 감소하였으나 부양 부담은 통계적으로 유의하게 증가하였다. 결론: 장기요양보험제도는 수급자들의 입원 서비스 이용과 의료비 부담을 통계적으로 유의하게 감소시켰다. 따라서 정부는 요양병원 또는 요양시설에 입원한 환자들을 조정할 수 있는 전문가를 양성하...ope

Association of Demographic and Socioeconomic Factors With Risk Factors for Chronic Kidney Disease

OBJECTIVES: The goal of this study was to examine the association of various demographic and socioeconomic factors with risk factors for chronic kidney disease (CKD). METHODS: We used nationally representative pooled data from the Korea National Health and Nutrition Examination Survey (KNHANES), 2007-2013. We estimated the glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease equation. We defined CKD as a GFR <60 mL/min/1.73 m(2), and 1304 of the 45 208 individuals included in the KNHANES were found to have CKD by this definition. The outcome variable was whether individual subjects adhered to the CKD prevention and management guidelines recommended by the Korea Centers for Disease Control and Prevention. The guidelines suggest that individuals maintain a normal weight, abstain from alcohol consumption and smoking, manage diabetes and hypertension, and engage in regular exercise in order to prevent and manage CKD. RESULTS: This study found that individuals with CKD were more likely to be obese and have hypertension or diabetes than individuals without CKD. In particular, male and less-educated CKD patients were less likely to adhere to the guidelines. CONCLUSIONS: Although the prevalence of CKD, as indicated by the KNHANES data, decreased from 2007 to 2013, the prevalence of most risk factors associated with CKD fluctuated over the same time period. Since a variety of demographic and socioeconomic factors are related to the successful implementation of guidelines for preventing and managing CKD, individually tailored prevention activities should be developed.ope

The Effect of Economic Participatory Change on Unmet Needs of Health Care among Korean Adults

Background: The objective of this research is to investigate and provide analysis of the economic participatory change affecting the unmet needs of health care in Korean adults. Methods: We used Korea health panel 4th and 5th data of 10,261 adults. The method of investigation is threefold. First, We identified the regional factors affecting unmet needs of health care. Second, we analyzed the effect of economic participatory change as it affects the unmet needs of health care. Third, we also investigated whether there were discernable differences between the age subgroups. Results: It was determined that influencing factors included sex, education, economic level, and health status. And after the subgroup analysis of age, we found that the economic participatory change was associated with the economical unmet needs of health care especially for those over 40 years of age. Also the population are facing unemployment enduring particular economic hardship in meeting their medical needs. Conclusion: This study finds that there are some policy recommendations for the sake of medical service equality. Medical welfare policy for those 40 years of age and older has been identified as an area that needs improvement. And considering that those 40 years of age and older are facing unemployment enduring particular economic hardship in meeting their medical needs, this study finds a need for government sponsored medical stipends or subsidizing of medical premiums, co-payment, and other fees.ope

Employment status and unmet dental care needs in South Korea: a population-based panel study

OBJECTIVES: This study was designed to evaluate whether employment status is associated with the experience of unmet dental care needs. METHODS: A total of 4620 workers were retrieved from Korea Health Panel data (2010-2013), and potential relationships were explored among their income levels, changes in employment and unmet dental care needs. RESULTS: Among the 4620 workers, 17.3% said they had failed at least once to get dental treatment or check-up, despite their needs. Precarious workers and those not in employment were more likely to experience unmet dental care needs due to economic burden compared with permanent workers (OR 1.36, 1.40, respectively). In addition, people in low-income group were 4.46 times more likely to experience unmet dental care needs caused by economic burden, compared with those with the highest income. CONCLUSION: This disparity means that precarious workers and those not in employment are more likely to face barriers in obtaining needed health services. Given the insecure employment status of low income people, meeting their healthcare needs is an important consideration.ope

Health care utilization and costs among medical-aid enrollees, the poor not enrolled in medical-aid, and the near poor in South Korea

BACKGROUND: Although government has implemented medical-aid policy that provides assistance to the poor with almost free medical services, there are low-income people who do not receive necessary medical services in Korea. The aim of this study is to highlight the characteristics of Medical-Aid enrollees, the poor not enrolled in Medical-Aid, and the near poor and their utilization and costs for health care. METHODS: This study draws on the 2012 Korea Welfare Panel Study (KOWEPS), a nationally representative dataset. We divided people with income less than 120% of the minimum cost of living (MCL) into three groups (n = 2,784): the poor enrolled in Medical-Aid, the poor not enrolled in Medical-Aid (at or below 100% of MCL), and the near poor (100-120% of MCL). Using a cross-sectional design, this study provides an overview of health care utilization and costs of these three groups. RESULTS: The findings of the study suggest that significantly lower health care utilization was observed for the poor not enrolled in Medical-Aid compared to those enrolled in Medical-Aid. On the other hand, two groups (the poor not enrolled in Medical-Aid, the near poor) had higher health care costs, percentage of medical expenses to income compared to Medical-Aid. CONCLUSION: Given the particularly low rate of the population enrolled in Medical-Aid, similarly economically vulnerable groups are more likely to face barriers to needed health services. Meeting the health needs of these groups is an important consideration.ope

The effect of cost-sharing in private health insurance on the utilization of health care services between private insurance purchasers and non-purchasers: a study of the Korean health panel survey (2008-2012).

BACKGROUND: Private health insurance in South Korea mainly functions as supplementary and complementary health insurance that compensates for insufficient coverage by National Health Insurance. However, full private coverage of public sector cost-sharing led to the problem of encouraging moral hazard-induced utilization, resulting in a policy change that occurred in October 2009. At that time, the Korean government introduced a minimum cost-sharing policy for indemnity health insurance. The purpose of this study was to analyze the effect of cost-sharing in private health insurance on health care utilization. METHODS: We analyzed data collected from the Korean Health Panel Survey from October 2008 to December 2011. We restricted the two groups to 803 purchasers with indemnity health insurance and 7023 non-purchasers who did not obtain any private health insurance. A difference-in-difference analysis was used to evaluate the effect of the 2009 policy. RESULTS: After the policy change, the utilization of outpatient visits by purchasers gradually decreased more than non-purchasers (0.015 in 2009 [p = 0.758], -0.117 in 2010 [p < 0.016], and -0.140 in 2011 [p = 0.004]). However, utilization of inpatient services was not statistically significant. Notably, the magnitude of the cost-sharing effect in indemnity health insurance was stronger for those receiving medical aid. Among this group, utilization of outpatient services (after the policy change in 2009) decreased more so than non-purchasers. Patients with three or more chronic diseases have not changed their health care utilization. CONCLUSIONS: Our results implied meaningful lessons for decision-makers and future health insurance policies in Korea and other countries in terms of cost-sharing in medical care. When policy makers intend to implement the cost-sharing, a different copayment scheme is needed according to the socioeconomic status or disease severity.ope

Effects of number and gender of offspring on quality of life among older adults: evidence from the Korean Longitudinal Study of Aging, 2006-2012

OBJECTIVES: We examined correlations between number and gender of offspring and health-related quality of life (HRQoL) and quality of life (QoL) in older adults. SETTING: We used data from the 2006-2012 data sets of the Korean Longitudinal Study of Aging. PARTICIPANTS: There were 10,242, 8680, 7907 and 7480 participants in 2006, 2008, 2010 and 2012, respectively. INTERVENTIONS: Number and gender of offspring. PRIMARY AND SECONDARY OUTCOME MEASURES: We measured participants' QoL and HRQoL using a visual analogue scale developed by the Korea Labour Institute and which is similar to the EQ-VAS, a European measure. RESULTS: We estimated the HRQoL and QoL of individuals with offspring. Estimates for the HRQoL and QoL of parents with no offspring were -7.762 and -9.384, respectively (both p<0.0001) versus parents with two offspring. For parents with five or more offspring, the estimates for the HRQoL and QoL were -1.529 and 0.885, respectively (p<0.001 and p<0.017, respectively) compared with parents with two offspring. For fathers with no offspring compared with fathers with two offspring, the estimates for the HRQoL and QoL were -6.143 and -7.492, respectively (both p<0.0001). CONCLUSIONS: These results suggest that number of offspring is associated with both HRQoL and QoL. Those with no offspring showed the lowest HRQoL and QoL. Although having five or more children had positive associations with QoL, it had negative associations with HRQoL. Public health services for those with poor quality of life should provide effective support programmes and services based on these findings.ope

The temporal association of excessive health expenditure with suicidal ideation among primary income earners: a cross-sectional design using the Korean Welfare Panel Survey (KoWePS)

OBJECTIVE: Excessive health expenditure (EHE) is a global issue for households suffering from high-cost medical conditions, low incomes and limited insurance coverage. After the international financial crisis of 2008, EHE became a social problem in developed countries. Such economic crisis might induce severe mental stress, resulting in suicidal ideation. METHODS: We used the Korean Welfare Panel Study (KoWePS) from 2011 to 2013 and selected primary income earners, who were defined as practical and economic representatives of households; the total number of analysed samples was 4247 of 5717 households in the database. We only included households that had never experienced EHE before 2011. To examine the temporal relationship between EHE and suicidal ideation, we conducted a logistic regression analysis. RESULTS: Among 4247 participants, 146 (3.4%) experienced suicidal ideation, whereas 4101 (96.6%) did not. One scale of depression score (OR=1.28, CI 1.23 to 1.34, p<0.001) was associated with increased suicidal ideation. Such ideation was influenced to a greater extent by a recent EHE above 10% of disposable income (OR=1.91, CI 1.16 to 3.15, p=0.012) than by either a remote EHE (OR=1.29, CI 0.71 to 2.32) or one in 2011 and 2012 (OR=1.67, CI 1.01 to 2.78, p=0.048). CONCLUSIONS: In this study, more recent EHE resulted in more suicidal ideation. In conclusion, we suggest that recent household EHE might be considered as an important factor to prevent suicidal ideation and to improve the mental health of individuals.ope

The effect of high medical expenses on household income in South Korea: a longitudinal study using propensity score matching

BACKGROUND: Almost 97% of the Korean population is covered by National Health Insurance and are entitled to receive the same level of insurance benefits, regardless of how much each enrollee contributes to the system. However, the percentage of out-of-pocket payments is still high. This study examines whether the incurrence of high medical expenses affects household income. METHODS: We use the Korea Welfare Panel and select 4,962 households to measure repeatedly over 5 years. Using propensity score matching, we set households with medical expenses of three times the annual average as "occurrence households" while "non-occurrence households" are those below the cut-off but with all other factors, such as income, held constant. We analyze whether the income of occurrence households differs significantly from the comparison group using a linear mixed effect model. RESULTS: After the occurrence of high medical expenditure, occurrence households (n = 825) had US$1,737 less income than non-occurrence households. In addition, the income of households (n = 200) that incurred high medical costs repeatedly for 2 years was US$ 3,598 lower than the non-occurrence group. CONCLUSIONS: Although it is important for the government to focus on medical assistance for households that have medical expense burdens, it needs to consider providing income indemnity insurance to protect them.ope

고성능 스토리지를 활용한 초고속 SAN 환경 구현

학위논문 (석사)-- 서울대학교 대학원 : 전기·컴퓨터공학부, 2013. 2. 염헌영.오늘날 서버 시스템 환경은 급속도로 증가하는 데이터를 효율적으로 처리 및 저장하기 위해 네트워크로 연결된 다수의 머신들로 clustering 이나, 분산시스템, 또는 SAN(Storage Area Network) 환경 등을 구성하여 보다 효율적인 서버 시스템을 구현하고 있다. 이러한 서버 시스템 환경에서의 performance bottleneck은 주로 스토리지 디바이스이며, 이를 극복하기 위해 고성능 스토리지 시스템에 대한 요구가 증가하고 있다. 하지만 단순히 스토리지 장비를 교체하는 것만으로는 고성능 스토리지의 뛰어난 성능을 제대로 활용할 수 없으며, 그에 맞는 최적화 작업이 필요하다. 본 연구에서는 먼저 기존의 SAN환경에 고성능 스토리지 장비를 적용해보았고, 초고속 네트워크 장비를 사용했음에도 불구하고 small size random I/O에 대해서는 빠른 디바이스 장비의 뛰어난 성능을 제대로 활용할 수 없음을 확인하였다. 이에 우리는 고성능 스토리지 장비의 성능을 최대한 활용할 수 있는 SAN solution 개발을 목적으로 기존의 SAN I/O path에서 존재하던 software overhead를 없애고, 고성능 스토리지의 bandwidth를 최대한 활용할 수 있도록 I/O 처리과정에서의 parallelism을 높였으며, RDMA 전송방식을 사용하는 초고속 네트워크 환경에서 small size random I/O의 성능 향상을 위해 temporal merge mechanism 을 적용한 새로운 data transfer protocol 을 제안하였다. 또한 이를 Prototype 형태로 구현하여 latency와 bandwidth 측면에서 높은 성능 향상을 확인하였다.초록 iii 목차 v 표 목차 vii 그림 목차 viii 제 1 장 서론 1 제 2 장 배경 6 2.1 High Performance storages 6 2.2 Traditional SAN I/O Path 7 2.3 Existing SAN Solution with Infiniband 8 제 3 장 Design Exploration 10 3.1 SAN I/O Path 상의 소프트웨어 오버헤드 제거 10 3.2 Increase Parallelism 12 3.3 Temporal Merge 14 제 4 장 Implementation Details 18 4.1 Block RDMA Protocol (BRP) 18 4.2 BRP Target 21 제 5 장 실험 및 검증 25 5.1 Latency & Bandwidth 26 5.2 BRP 성능 분석 30 5.3 Real Workload Evaluation 35 제 6 장 관련 연구 37 제 6 장 향후 과제 38 제 7 장 결론 39 참고 문헌 41 ABSTRACT 45Maste