Health Policy Manag.  2015 Sep;25(3):185-196. 10.4332/KJHPA.2015.25.3.185.

Refinement and Evaluation of Korean Outpatient Groups for Visits with Multiple Procedures and Chemotherapy, and Medical Visit Indicators

• Park H
• Kang GW
• Yoon S
• Park EJ
• Choi S
• Yu S
• Yang EJ

• KMID: 2165250
• DOI: http://doi.org/10.4332/KJHPA.2015.25.3.185

Abstract

BACKGROUND
Issues concerning with the classification accuracy of Korean Outpatient Groups (KOPGs) have been raised by providers and researchers. The KOPG is an outpatient classification system used to measure casemix of outpatient visits and to adjust provider risk in charges by the Health Insurance Review & Assessment Service in managing insurance payments. The objective of this study were to refine KOPGs to improve the classification accuracy and to evaluate the refinement.
METHODS
We refined the rules used to classify visits with multiple procedures, newly defined chemotherapy drug groups, and modified the medical visit indicators through reviews of other classification systems, data analyses, and consultations with experts. We assessed the improvement by measuring % of variation in case charges reduced by KOPGs and the refined system, Enhanced KOPGs (EKOPGs). We used claims data submitted by providers to the HIRA during the year 2012 in both refinement and evaluation.
RESULTS
EKOPGs explicitly allowed additional payments for multiple procedures with exceptions of packaging of routine ancillary services and consolidation of related significant procedures, and discounts ranging from 30% to 70% were defined in additional payments. Thirteen chemotherapy drug KOPGs were added and medical visit indicators were streamlined to include codes for consultation fees for outpatient visits. The % of variance reduction achieved by EKOPGs was 48% for all patients whereas the figure was 40% for KOPGs, and the improvement was larger in data from tertiary and general hospitals than in data from clinics.
CONCLUSION
A significant improvement in the performance of the KOPG was achieved by refining payments for visits with multiple procedures, defining groups for visits with chemotherapy, and revising medical visit indicators.

Keyword

Oupatient care, classification; Insurance claim review; Fee-for-service plans; Prospective payment system; Health care costs

MeSH Terms

Classification
Drug Therapy*
Fee-for-Service Plans
Fees and Charges
Health Care Costs
Hospitals, General
Humans
Information Systems
Insurance
Insurance Claim Review
Insurance, Health
Outpatients*
Product Packaging
Prospective Payment System
Referral and Consultation