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Keywords:

  • case managers;
  • costs;
  • healthcare services;
  • Korea;
  • Medical Aid;
  • nursing;
  • overuse

shin s.m., kim m.j., kim e.s., lee h.w., park c.g. & kim h.k. (2010) Medical Aid service overuse assessed by case managers in Korea. Journal of Advanced Nursing66(10), 2257–2265.

Abstract

Aim.  This paper is a report of a study conducted to describe characteristics of overusers of the Medical Aid service, assess appropriateness of overusers’ medical service use, and determine contributing factors to medical aid overuse in Korea.

Background.  Medical Aid use in Korea has increased in recent years, but no systematic studies reported the characteristics of overusers and appropriateness of their medical service use.

Method.  In a cross-sectional study, case managers conducted interviews, evaluated participants’ insurance claim data, and determined overusers by the case managers’ determination of the appropriateness of their medical service use and their expenditures during the year of 2006. Descriptive statistics, chi-square analysis, analysis of variance, and multiple logistic regression were used for data analysis.

Result.  Most heavy users were elderly, female, less educated, and had stress, lower perceived health status and multiple clinic visits. Twenty-five per cent of inpatients and 63·9% of outpatients were classified as overusers. The average total cost per capita of an overuser was 43·3% higher than that of an optimal user. Age, education, stress, arthritis, multiple clinic visits and frequent clinic visit recommendations by providers were statistically significant contributing factors to the overuse.

Conclusion.  Preventive measures are needed to decrease the overuse of Medical Aid in Korea; such measures should focus on characteristics contributing to overuse, including the provider-induced demand for more clinic visits. Case managers could play an important role as gatekeepers, managers, and educators for optimal use of Medical Aid in Korea and elsewhere in the world that faces similar problems.