Health Policy Manag.  2020 Mar;30(1):72-81. 10.4332/KJHPA.2020.30.1.72.

An Aanalysis of Predictive Factors of Medical Service Overuse for Inpatients Applied Out-of-Pocket Maximum in Long-Term Care Hospitals in South Korea

• Lim S
• Shin H

• KMID: 2507287
• DOI: http://doi.org/10.4332/KJHPA.2020.30.1.72

Abstract

Background
The out-of-pocket maximum is one of the distinctive healthcare systems which sets a ceiling on co-payment in order to reduce the burden of households from the unpredictable medical expenditure. However, this leads to an increase in the demand for healthcare services especially in long-term care hospitals (LTCHs) in Korea.
Methods
This study analyzed the influence factor of medical service overuse of 165,592 inpatients in LTCHs which out-of-pocket maximum is applied, by utilizing data from the National Health Insurance Service (2016). Based on Anderson Model, the medical service overuse, as a dependent variable, was defined as long-stay admission more than 180 days at the LTCHs. Independent variable was comprised of predisposing factors (gender, age), enabling factors (income level, types of out-of-pocket maximum) and need factors (illness level, patient use of tertiary hospital).
Results
The most powerful factor of medical service overuse in LTCHs was availability of pre-payment for the out-of-maximum (odds ratio [OR], 191.66; p<0.001). This tendency was found in high income level status (p<0.001). Furthermore, mild inpatients (OR, 1.50; p<0.001) which had no experience with the tertiary hospitals (OR, 2.06; p<0.001) were more relevant to the medical service overuse in LTCHs, compared to the severe inpatients.
Conclusion
It is suggested that a separate standard of out-of pocket maximum with regards to LTCHs is required to secure the beneficial functions of long-term hospitals and prevent unnecessary financial leakage to achieve sustainable and financially sound National Health Insurance.

Keyword

Out-of-pocket maximum; Long-term care hospitals; Medical service overuse; Long-stay admissions; Mild inpatients