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釜山靑十字 醫療保險 加入者 保險外醫療利用에 關한 硏究

Out-of-Plan Medical Care Utilization for Menbers of Busan Blue Cross Medical Cooperative

공중보건잡지 1976년 13권 2호 p.317 ~ 324
김영웅, 文玉綸,
소속 상세정보
김영웅 (  ) - 서울대학교 보건대학원
文玉綸 (  ) - 서울대학교 보건대학원

Abstract


This study was aimed to identify the pattern of out-of-plan medical care utilization and the magnitude of out-of-plan expenditure for members of the Busan Blue Cross Medical Insurance Cooperative. One tenth of the enrollees (1,972 persons out of 20,282 persons) are selected on a systematic random sampling base.
Out-of plan medical care utilization exceeded Busan Blue Cross physicians 5.8%, and of pharmacist visits was 25.1%. Therefore, it is hardly possible to estimate the total amount of medical care utilization for the insured without the knowledge of their out-of-plan use.
It cost 1,902 won per patient for copayment of the members, and 6,689 won for out-of-plan visits to other medical facilities. The difference was 4,787 won. Therefore, it cost 3.5 times more per patient in the visits to other medical facilities. It cost 748 won per visit to the Blue Cross, and 2,151 won to other medical facilities. The difference was 1,403 won. The latter cost 2.9 times more per visit than the former. It cost 323 won per member for the Blue Cross use, 376 won for pharmacist visit. Therefore, it was cheapest in the Blue Cross use.´
The direct medical care expenditure of the insured member consists of monthly premium, coinsurance fee, and out-of-plan expenditure. It has shown that it cost 1,766 won per member per month(1,319 won if some expenditure such as health center and herb medicine use, and the expense related to superstition were excluded); premium 280 won, coinsurance fee 323 won, and out-of-plan expenditure 1,163 won. Two-thirds of direct medical care expenditure per member has come from out of the Blue Cross use.
In addition to the direct medical care expenditures, efforts are made to estimate the whole medical care expenditures which include the discounted expense from referred hospitals and the government subsidy. It cost 2,889 won per member per month, from which 40.3% (1,163 won) comes from out-of-plan use. The finding suggests that it is essential to have information on out-of-plan use if per capita medical care expenditures are accurately estimated.
It is urgently called for, first, to examine the patterns of out-of-plan use in other health plans, particularly in employees health plans, and, second, to explain the reasons why they spend so much for the out-of-plan use despite their eligibility for health plan benefits.

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