Revision and Evaluation of Korean Outpatient Groups-Korean Medicine

Jiseon Ryu; Byungmook Lim; Byungwook Lee; Changhoon Kim; Chang-ho Han; Ryu, Jiseon; Lim, Byungmook; Lee, Byungwook; Kim, Changhoon; Han, Chang-ho

doi:10.13048/jkm.14033

JKM > Volume 35(3); 2014 > Article

Ryu, Lim, Lee, Kim, and Han: Revision and Evaluation of Korean Outpatient Groups-Korean Medicine

Original Article

Journal of Korean Medicine 2014; 35(3): 93-102.

Published online: September 30, 2014

DOI: https://doi.org/10.13048/jkm.14033

Revision and Evaluation of Korean Outpatient Groups-Korean Medicine

Jiseon Ryu¹, Byungmook Lim¹^{, 2}, Byungwook Lee³, Changhoon Kim⁴, Chang-ho Han⁵

¹Research Institute for Korean Medicine, Pusan National University

²Division of Humanities and Social Medicine, School of Korean Medicine, Pusan National University

³Department of Korean Medicine Classics and History, College of Korean Medicine, Dongguk University

⁴Department of Preventive Medicine, School of Medicine, Pusan National University

⁵Department of Internal Medicine, College of Korean Medicine, Dongguk University

Correspondence to: 임병묵 (Byungmook Lim), 경상남도 양산시 물금읍 부산대학로49 부산대학교한의학전문대학원 인문사회의학부 316호, Tel: +82-51-510-8453, Fax: +82-51-510-8446, E-mail: limb@pusan.ac.kr

Received July 30, 2014 Revised September 16, 2014 Accepted September 16, 2014

Abstract

Objectives:

This study aimed at revising the Korean Out-patient Groups for Korean Medicine (KOPG-OM, version 1.0) based on clinical similarity and resource use, by using the accumulated claims data, and evaluating the validity of the revised classification system.

Methods:

A clinical specialist panel involving 19 specialists from 8 Korean medicine (KM) specialty areas reviewed the classification tree, diagnosis groups and procedure groups in terms of clinical similarity. Several models of outpatient grouping were formulated, with the validity of each tested based on the R² coefficient of determination for the treatment costs of all visits. To add age splits, the variances of treatment costs by age groups were also analyzed. These statistical analyses were performed using KM claims data of National Health Insurance from 2010 to 2012.

Results:

The classification tree designed via panel discussions was used to allocate outpatient cases to 26 diagnosis groups, with cases involving procedures such as acupuncture, moxibustion and cupping, then allocated to 9 procedure groups in each diagnosis group. The cases without procedures were categorized into the visit index - medication group. This process resulted in 298 outpatient groups. The R² values for treatment costs of all visits ranged from 0.38 to 0.69 depending on the providers' types.

Conclusions:

The revised model of KOPG-KM has a higher validity for outpatient classification than the current system and can provide better management of the costs of outpatient care in KM.

Keywords: Korean outpatient groups, patient classification system, Korean medicine

Fig. 1.

Classification Flow for KOPG-KM

Table 1.

26 Disease Groups in KOPG-KM

Oder	KCD-6 code	Name
1	A00-B99	Infectious and parasitic diseases
2	C00-D48	Neoplasms
3	D50-D89	Diseases of the blood and immune mechanism
4	E00-E90	Endocrine, nutritional and metabolic diseases
5	F00-F99	Mental and behavioral disorders
6	G00-G99	Diseases of the nervous system
7	H00-H95	Diseases of the eye and adnexa
8	I00-I99	Diseases of the circulatory system
9	J00-J22	Acute respiratory diseases
10	J30-J99	Chronic respiratory diseases
11	K00-K99	Diseases of the digestive system
12	L00-L99	Diseases of the skin and subcutaneous tissue
13	M00-M36	Diseases of the joints and connective tissue
14	M60-M99	Diseases of the back and spine
15	M40-M54	Diseases of the musculoskeletal system
16	N00-N99	Diseases of the genitourinary system
17	O00-O99	Pregnancy, childbirth and the puerperium
18	P00-Q99	Certain conditions originating in the perinatal period
19	R00-R99	Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
20	S00-S99	Musculoskeletal injury
21	T00-T99	Injury, poisoning and certain other consequences of external causes
22	Z00-Z99/U00-U19	Factors influencing health status, contact with health services, and codes for special purposes
23	U20-U39	KM diseases
24	U50-U59	KM disease patterns of external contraction
25	U60-U79	KM Qi, blood, organs diseases patterns
26	U95-U98	KM Sasang constitutional medicine diseases patterns

Table 2.

9 Medication- Procedure Groups in KOPG-KM

Oder	Name
1	non-acupuncture
2	single acupuncture
3	multiple acupuncture
4	single acupuncture+moxibustion
5	multiple acupuncture+moxabustion
6	single acupuncture+cupping
7	multiple acupuncture+cupping
8	acupuncture+moxibustion+cupping
9	medication+procedures

Table 3.

Divided Age Groups in KOPG-KM

Disease groups	Medication-procedure groups	Age (years)
G00-G99 Diseases of the nervous system	single acupuncture+cupping	0–64 / >64
	multiple acupuncture+moxabustion	0–64 / >64
	multiple acupuncture	0–64 / >64
	medication+procedures	0–64 / >64

K00-K99 Diseases of the digestive system	single acupuncture+cupping	0–64 / >64
	multiple acupuncture+moxabustion	0–64 / >64
	multiple acupuncture	0–64 / >64
	medication+procedures	0–17/ 18–64/ >64

M00-M36 Diseases of the joints and connective tissue	single acupuncture+moxibustion	0–64 / >64
	single acupuncture+cupping	0–64 / >64
	multiple acupuncture+moxabustion	0–64 / >64
	multiple acupuncture	0–64 / >64
	medication+procedures	0–64 / >64

40-M54 Diseases of the musculoskeletal system	single acupuncture+moxibustion	0–64 / >64
	single acupuncture+cupping	0–64 / >64
	multiple acupuncture+moxabustion	0–64 / >64
	multiple acupuncture	0–64 / >64
	medication+procedures	0–64 / >64

M60-M99 Diseases of the back and spine	single acupuncture+moxibustion	0–64 / >64
	single acupuncture+cupping	0–64 / >64
	multiple acupuncture+moxabustion	0–64 / >64
	multiple acupuncture	0–64 / >64
	medication+procedures	0–64 / >64

R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified	single acupuncture+cupping	0–64 / >64
	multiple acupuncture+moxabustion	0–64 / >64
	multiple acupuncture	0–64 / >64
	medication	0–17/ >17
	medication+procedures	0–17/ 18–64/ >64

U20-39 KM diseases	single acupuncture+cupping	0–64 / >64
	multiple acupuncture+moxabustion	0–64 / >64
	multiple acupuncture	0–64 / >64
	medication	0–17/ >17
	medication+procedures	0–17/ 18–64/ >64

Table 4.

R² of KOPG-OM vs. Revised Model (KOPG-KM)

		KM clinic data		KM hospital data
		N(visit)	R² (%)	N(visit)	R² (%)
KOPG-OM	2010 data	94,025,463	9.50	-	-
	2011 data	94,971,038	9.87	-	-
	2012 data	23,388,209	9.75	731,670	22.80
Revised model (KOPG-KM)	2010 data	94,385,071	39.09	3,044,347	69.41
	2011 data	95,056,203	44.12	3,132,393	38.26
	2012 data	23,397,537	46.57	709,780	46.64

참고문헌

1.. Health Insurance Review & Assessment Service. KOPG-OM Classification, (2011). Preface 1–2.

2.. Health Insurance Review & Assessment Service. KOPG Classification. Version 1.1.2011. Preface 1–2.

3.. Health Insurance Review & Assessment Service. T/F Operating Result for Development of KOPG-OM and Computerized Classification Program. 2006. 14-46.

4.. Averill, RF, Goldfield, NI, Wynn, ME, & McGuire, TE, et al. Design of Prospective Payment Patient Classification System for Ambulatory Care. Healthcare Financing Review, (1993). Fall. 15(1), 71-100.

5.. Averill, RF, Muldoon, JH, Vertees, JC, Goldfield, NI, Mullin, RL, & Fineran, EC, et al. The Evolution of Casemix Measurement Using Diagnosis Related Groups. 3M Health Information System, Wallingford, Connecticut, (1999). 5-98.

6.. Fetter, RB, & Freeman, JL. Diagnosis-related groups: Product Line Management within Hospitals. Academy of Management Review, (1986). 11(1), 41-54.

7.. Reid, B, Palmer, G, & Aisbett, C. The Performance of Australian DRGs. Australian Health Review, (2000). 23(2), 20-31.

8.. Palmer, G, & Reid, B. Evaluation of Performance of Diagnosis-Related Groups and Similar Casemix System; Methodological Issues. Health Services Management Research, (2001). 14(2), 71-81.

9.. Park, HY, Kang, GW, & Koh, Y. Development of Korean Ambulatory Patient Groups. Korean J. Health Policy & Administration, (2006). 16(1), 17-40.

10.. Sanderson, HF, Anthony, P, & Mountney, LM. Healthcare Resource Groups Version 2. J. of Public Health Medicine, (1995). 17(3), 349-354.

11.. Jurgen, S, & Emanuel, K. Homogeneity of the German Diagnosis-Related Groups. Health Services Management Research, (2010). 23(4), 154-159.

12.. Shin, YS, Lee, YS, Park, HY, & Yeom, YK. Development and Evaluation of Korean Diagnosis Related Groups: Medical service utilization of inpatients. Korean J. of Preventive Medicine, (1993). 26(2), 293-309.

13.. Kang, KW, Park, HY, & Shin, YS. Refinement and Evaluation of Korean Diagnosis Related Groups. Korean J. of Health policy & Administration, (2004). 14(1), 122-147.

14.. Park, HY, Park, KD, & Shin, YS. On Feasibility of Ambulatory KDRGs for the Classification of Health Insurance Claims. Korean J. of Health policy & Administration, (2003). 13(1), 98-115.