최신 입원환자분류체계를 반영한 전문병원 지정기준 개선 연구

Abstract

Background: Since 2011, the Korean government has been implementing a program for the designation of specialized hospitals (SHs). Hospitals can earn this designation following a successful application and subsequent evaluation. One of the requirements for this designation is the volume of care, which is determined by the total length of stay (LOS) of patients receiving specialty care (PSC). This is also measured using the Korean Diagnosis Related Group (KDRG) code. Currently, the KDRG version (“v”) 3.5 is being used for the designation process, even though the most recent version is v4.4. Objective: The aim of this study was to examine changes in the volume of care at SHs and general hospitals (GHs), as well as the removal of certain hospitals from the existing SH list when updating KDRG from v3.5 to v4.4. Additionally, this study aimed to propose several policy implications for SHs in light of the update. To achieve these objectives, we analyzed health insurance claim data for the year 2022 and the mapping table between KDRG v3.5 and v4.4. Results: As of January 2023, there were a total of 113 SHs. An analysis of 94 SHs and 1,907 GHs, excluding oriental medicine hospitals, revealed that the total LOS for PSC was 321,206 days. The average LOS for all patients in SHs was shorter than that of GHs (6.69 versus 9.57 days). However, when only PSC was analyzed, the average LOS in SHs was longer than in GHs (9.0 versus 8.4 days). Significant changes in LOS among hospitals were observed when the KDRG was updated from v3.5 to v4.4. Regarding the requirement that the LOS of hospitals applying for SH status should be within the 30th percentile in the order of the sum of LOS of PSC, the application eligibility change of all hospitals for SHs is as follows. The number of hospitals losing SH application eligibility decreased most significantly in the neurology specialty, at 162 (34.1%), followed by otolaryngology at 52 (18.6%), and spine diseases at 69 (18.1%). This loss of eligibility was associated with the code segmentation and introduction of new codes in KDRG v4.4. Hospitals that lost eligibility were more likely to provide medical care not covered by these codes. When the KDRG was updated from v3.5 to v4.4, two SHs fell out of the designation criteria among the current 113 SHs. The segmentation of KDRG codes, the creation of new classification codes, and other factors influenced this change. An analysis of the 1:1 mapping table between the two versions revealed that the table for KDRG v4.4 has 1,122 unique and 29 missing codes, totaling 1,151 codes after excluding 6 patient classification error codes. The analysis also showed that the number of codes with different code compositions (or letters), but the same name (meaning) was 707 cases (61.4%), and the number of codes with exactly the same code and meaning with 1:1 mapping was 101 cases (8.8%). This study suggests two policy implications from the standpoint of institutions and the managerial efficiency of SHs. For the former, it is necessary to standardize different KDRG versions with consistent comparability, establish perfect mapping master files between different versions, deregulate the requirement of SHs in terms of volume of care, and introduce a healthcare cost index as a requirement for SHs, which could replace the volume of care for PSC. For the latter, it is necessary to add functions that produce statistics on SHs within the Online Analytical Processing (OLAP) System and construct a “Specialized Hospital Management Information System (SHIS)” on the internal network of the Health Insurance Review and Assessment Service (HIRA) for managerial support for SHs. Discussion: The current study reveals significant changes in the volume of care for PSC across various hospitals upon the application of the latest KDRG v4.4. However, this application only impacted two existing SHs. The current KDRG exhibits little consistency in terms of code composition, meanings, and the mapping table between versions. Therefore, it is necessary to establish a standardized code scheme for KDRG, create a comprehensive mapping table for each version, and construct the SHIS within HIRA’s internal network for managing SHs.