韓國 醫療保險制度의 問題点 및 改善方案에 관한 硏究

김세연 경기대학교 대학원 1983 국내석사

I. Introduction The purpose of this treatise is to help to establish Medical Care Insurance System appropriate to Korean situation by analyzing the present Medical Care Insurance System in Korea, extracting problems and researching into improvement measures thereto. In accordance with this, I reviewed Medical Care Insurance System in Chapter 2 and the present situation of Medical Care Insurance System in Korea in Chapter 3. In Chapter 4, I extracted problems and suggested improvement measures thereto in Chapter 5. Lastly I concluded this treatise by summarizing the results of afore-mentioned review. II. Outline of the Medical Care Insurance System In general, the medical care insurance has its own peculiarities different from other insurance systems. These peculiarities will he examined from three aspects: (1) Subjectivity of insurance benefits, (2) determination of insurance benefits, and (3) limitations of insurance benefits. And the structure of medical care insurance system will be considered from three viewpoints: (1) the operating organ, (2) the kinds of insurance benefits, and (3) the burden of expense of the medical care insurance. III. Present Situation of Medical Care Insurance System in Korea Our present medical care insurance system can he divided into a medical care insurance system based on the Medical Care Insurance Act and another system based on the Civil Servants and Private School Faculty Medical Care Insurance Act. Here will be discussed and analyzed the present situation of each insurance system, its managing institution, its size and financial conditions, the number of recipients and their rate of participation, the number of medical care institutions, the number of medical examinations, and so on. IV. Problems of Our Medical Care Insurance System The problems brought forward through analyzing of our present medical care insurance system are narrow scope of participants, excessive use of medical care institutions by particular beneficiaries, deficiencies in manpower and facilities, concentration of medical care institutions in cities, deficiencies in services provided, unrealistic medical care prices and procedures for payment of medical treatment, necessity to enlarge the designated convalesing facilities, financial problems of the associations, and so on. V. Reform Measures for the Korean Medical Care Insurance System Various methods for the efficient management and the perfecting of its contents involve the realization of a regional medical care insurance system, the reasonable management of insurance finances, the improvement in calculating the medical treatment costs and insurance benefits, the expansion of medical care facilities, regulation on medical care distribution systems, and so on. VI. Conclusion To develop a medical care insurance system more suited to our reality, the concerned authorities, the insured, the medical care insurance organizations and other related parties must improve the problems and imperfections of the present medical care insurance system, their mutual positive cooperation, with the ultimate aim of accomplishing the national medical care protection.

국민건강보험법상 요양급여제도에 관한 헌법적 고찰 : 건강보험 보장성 강화를 위한 법제 개선방향을 중심으로

정선우 고려대학교 대학원 2019 국내석사

Since the early 2000s, when the application of National Health Insurance was mandated to all citizens and insurance carriers were integrated, discussions on the expansion and augmentation of coverage have been ongoing. Even today, enhancing coverage is one of the most contentious issues regarding National Health Insurance. However, despite consistent enforcement of government policy to enhance coverage and considerable investment in health insurance, the coverage rate of health insurance for incurred medical charges covered has been stagnant in the low 60 % for the past decade. It is incontestable that enhancing National Health Insurance coverage has constitutional justification since the Korean Constitution adopts the Social State Principle as one of its fundamental constitutional principles. Even so, enhancing National Health Insurance coverage within the realistic context of limited health care resources and insurance finance necessitates the establishment of principles and standards derived from a social consensus regarding the specific health care services that should be included in National Health Insurance benefits, determination of the health care services that should be provided first, and establishment of standards for the measures that should be undertaken to reduce patient co-payments. Moreover, there should be measures to protect the rights of health care providers, since transferring health care services as insurance benefits within the National Health Insurance system inevitably restricts the freedom of health care providers operating medical institutions. Therefore, there is the need for examination from a constitutional perspective regarding the limitation of improving coverage of National Health Insurance provided by a constitutional state and approaches to ensure procedural justification based on a democratically-derived consensus over policy decisions regarding coverage augmentation. Such research should start from an investigation of problems and formulation of improvement options for the health care benefit system with the aim of determining the level of National Health Insurance coverage and concomitant health care benefit standards that regulate such system. Thus, the purpose of the present study is as follows: examination of the health care benefit system and its standards, which function as legal and systematical means to increase National Health Insurance coverage regarding medical expenses; analysis of the deviation of the current legal system from constitutional standards; identify options to ameliorate such problems; and generation of measures to secure sustainability of coverage expansion based on the premise of limited resources. This thesis consists of three main sections: Chapter 2 (Social State Principle and the Demand for Coverage Expansion); Chapter 3 (Importance and Issues of Health Care Benefit System regarding Improving Health Insurance Coverage); and Chapter 4 (Direction of Health Care Benefit System Development to Enhance Sustainable Coverage). Chapter 2, by examining the constitutional significance of the Social State Principle and the structure that actualizes the right to public health as a medical security system within the social security system and investigating the significance of public medical security and limitations of national intervention, provides the theoretical background of this study. Based on such examination, a theoretical foundation is provided for establishing the principles and standards for coverage improvement. Through such theoretical background, an overview of the historical development of Korea’s National Health Insurance is provided as the foundation, based on which coverage improvement of the National Health Insurance has become the prevailing major health policy agenda. In addition, to analyze the problems of coverage improvement that the National Health Insurance is currently facing, the chapter examines the significance, current status, and specific methods of coverage improvement of the National Health Insurance system, factors to consider for coverage improvement, and policy-based efforts and limitations for coverage improvement. Chapter 3 analyzes the significance and provisions of the health care benefit system under the National Health Insurance Act, as well as the normative system of the health care benefit standards that regulate the system. Moreover, a specific normative structure for improving National Health Insurance coverage via the standards for health care benefits is examined to comprehend the system’s significance and importance and standards for coverage enhancement. Furthermore, based on the aforementioned role and importance of the health care benefit standards, the major issues of the health care benefit system with regards to coverage improvement are analyzed in three aspects, namely increasing benefits and adjusting co-payments, guaranteeing optimal medical charge and evaluating the cost of health care benefits. In Chapter 4, the principles and standards for National Health Insurance coverage augmentation is first examined as a premise to generate options to resolve the aforementioned problems of the system, followed by improvement measures. Also, the limitations of coverage augmentation and complementary measures for the health care benefit system are examined in the light of the following factors: restricted application of arbitrary non-benefit care and its appropriate management, reorganization of the medical expenses payment system, supplementation through private commercial health insurance, and reasonable role sharing. The results of this research can briefly be summarized as follows; Increasing National Health Insurance coverage specifically indicates enhancement of the level of benefits by expanding the range of National Health Insurance benefits or reducing patient co-payments. Therefore, coverage under the National Health Insurance is determined by the range and level of health care benefits which refer to the core medical service provided. The types and items of such health care benefits are listed in the benefit inventory announced by the Minister of Health and Welfare. For each item of health care benefit, a set, fixed cost of health care benefit and patient co-payment are provided based on the treatment-based payment system. As such, the range and items of health care benefits are ultimately finalized by cost evaluation of the health care benefit by the Health Insurance Review and Assessment Service. The norms that form and regulate the specifics of the health care benefit system provided by the National Health Insurance, such as the benefits’ subject and range, their cost calculation and bearing, and evaluation thereof, are referred to as the standards for health care benefit. The standards for health care benefit regulate the range of medical services included in National Health Insurance benefits based on medical grounds and cost-effectiveness. Thus, the standards play a role in determining the priority of benefits and adjusting the level of benefits when extending the range of benefits, assessing the cost of benefits, and setting the co-payment level. The standards also become the basis for effective management of limited resources through cost evaluation of benefits. Moreover, the health care benefit standards have significance in providing the legal and systematic foundation for National Health Insurance coverage improvement functioning and restricting the fundamental rights of health care providers due to compulsory inclusion in the National Health Insurance system based on the system of medical institution designation. Enhancing National Health Insurance coverage cannot be achieved merely by increasing the rate of health insurance coverage. Based on modern National Health Insurance functions and roles, enhancing coverage indicates actualizing universal medical security; that is, when medical service is necessary to maintain, restore, or improve health, any eligible individual in such need shall receive corresponding medical service in quality (range of benefit) and quantity (level of benefit). However, due to realistic limitations such as limited medical resources and finances, enhancing coverage of the National Health Insurance should move towards guaranteeing access to essential medical services. So doing will enhance access to medical care by reducing the financial burden incurred from the use of medical service and achieve the purpose of the National Health Insurance, i.e., prevent those covered from becoming socially disadvantaged on account of onerous medical expenses. To enhance essential medical services coverage, the services should first be determined and included within the National Health Insurance benefit range, followed by determination of the appropriate level of financial burden incurred by individuals using them. However, defining essential medical service is difficult, likewise, among the various essential medical services, prioritizing the services to decide which medical service can be claimed first. Furthermore, setting an appropriate and fair level of financial burden for the service is also challenging. Therefore, to achieve coverage enhancement of health insurance, consistent principles and standards from a long-term perspective should be established legally and systematically based on democratic consensus. Such principles and standards reflecting prevailing social values should determine the overall direction of policy and play the role of mediating conflicting interests among stakeholders when making decisions for detailed policy. Under such principles and standards, National Health Insurance stakeholders, namely insurance policy holders, medical institutions, insurance carriers, and government, should engage in thorough discussions and consultations, and proceed through a reasonable and transparent decision-making process to determine major policies for coverage enhancement. Moreover, when pursuing coverage enhancement, the equilibrium between insurance premium inflows and insurance benefit outflows should be maintained. To avoid imprudent expansion of coverage that ignores the realistic limitations of insurance financing, a professional evaluation process based on the principle of public health insurance should be implemented. In addition, insurance budgets should be managed based on objective and reasonable health care benefit standards, and measures should be taken to guarantee sustainability of coverage improvement and observe limitations set by the constitutional state, such as securing optimal medical charges so that the property right and occupational freedom of health care providers operating medical institutions are not infringed. Based on the understanding of the health care benefit system and health care benefit standards that form the legal and systematic basis for National Health Insurance coverage enhancement, measures for such can be proposed as follows: (1) as improvement measure for expanding health care benefits and reducing co-payment, a Comprehensive Plan for National Health Insurance providing principles and standards for coverage improvement should be established, professional evaluation methods should be implemented, and the Deliberation Committee of National Health Insurance Policy should be administered democratically; (2) as for improvement measures to determine optimal medical charges, trust in medical expense negotiations should be established, the medical charges contracting system should more adequately guarantee freedom of contract, and adjustment and mediation for the decision of optimal medical charge should be provided when negotiations over medical expenses fail; (3) as for improvement measures for reasonable and fair evaluation of health care benefit cost, the evaluation system for such benefits should be restructured, objective and fair evaluation standards should be established, and the independence and professionalism of the Health Insurance Review and Assessment Service should be enhanced. For complementary measures of the health care benefit system regarding the limitations of coverage improvement of the National Health Insurance, the following are examined: (1) restricted application and appropriate management of arbitrary non-benefit care arising from the health care benefit system’s structural problems, (2) reorganization of the medical expenses payment system to resolve problems of the current treatment-based payment system, and (3) role sharing of commercial health insurance to supplement medical security limitations provided under the National Health Insurance.

韓國 醫療保險制度의 管理運營體系에 關한 硏究

권경득 건국대학교 대학원 1987 국내석사

The primary purpose of medical insurance system in modern welfare states is to provide equal opportunities of utilizing medical services for their people. Principles of universality, adequacy, equity and solidarity in relation to coverage and provisions of the insured are applied to achieve this purpose. If these principles be applied and put into practice in appropriate manner, the medical insurance system is expected to help to provide whole population with an adequate amount of medical services on an equitable basis and pay medical fees according to their ability to pay, and it is expected to make a contribution to the balanced development of the society by reducing the degree of inequalities among different social strata. The medical insurance system in Korea is also assumed to operate in the direction of the above - mentioned purpose and principles. But there were many problems during implementation of medical insurance system in Korea (1977-1986). Among these problems, medical insurance management system has been critically discussed and debated as one of the most cruciel issue for the development of medical insurance system. The current management system is significantly deviated from the proposed goal and principles because it is divided by the occupation and the locality of the insured. This study focuses on Medical Insurance Management System in Korea. For the purpose of this, (1) review characteristics of medical insurance system in relation to goal - means system of social security (2) analize the gaps between principles and implementation of medical insurance system in a view of management system and make an alternative proposal. More specifically, the contents of this paper are as follows: Ⅰ. Introduction Ⅱ. The characteristics of medical insurance system and the typology of management system. 1. social security and medical insurance system. 2. the typology of medical insurance management system. Ⅲ. The realities and problems of medical insurance management system in Korea. 1. the current situation of medical insurance system. 2. the reality of medical insurance management system. 3. the problems of medical insurance management system. Ⅳ. The improved proposal of medical insurance management system in Korea. 1. the comparative analysis of the current alternatives. 2. the efficient - improved proposal of medical insurance management system. Ⅴ. Conclusion Analizing the current distributed management system which was seleted in 1976, it can be found that the medical insurance policy was not decided on the values of welfarism but on the administrative convenience. Therefore, the government must re-establish a desirable medical insurance policy to cover all the uninsured and to realize the national medical insurance in the future. When the medical insurance policy is re-established, the values of welfarism and the principles of the desirable medical, which are considered In the process of reorganization of the social security and medical security system, must be respected. The medical insurance policy for the reorganization of management system must put the priority on, (1) constructing the founation to expend its coverage to the uninsured. (2) making its fees fair and equitable to all of the benefits, (3) making the management system effective, (4) making the medical cost be easily controlled. From this point of view, this study proposes "The National Intergrated Management Model" which is based on the national unit as an alternative for reoganization of the current distributed management system. This model is a management system which settles the problems of the -current distributed management system.

우리나라 의료보험제도에 관한 연구 : 현행 제도분석과 개선방안을 중심으로

이찬표 京畿大學校 行政大學院 1998 국내석사

In Korea the "Medical Insurance Law" was enacted in December 16 1963. But its implementation was postponed due to the insufficient social conditions. In July 1 1977 workplace medical insurance was introduced at companies with more than 500 employees and in January 1 1979 medical insurances for public servants and school teachers were put into practice. With the implementation of regional medical insurances both in rural and urban areas in January 1 1988 and July 1 1989 respectively, the current national medical insurance system has been completed. However, in the process of rapid expansion during the past 20 years, the medical insurance system has revealed many problems, causing various controversies about its resolution. The core of the debates is wether the insurers are to be integrated into one organization or they should be complemented maintaining current system. This study classified the problems of the present union-style medical insurance system into two groups, one related to the management system, the other the insurance payment system and tried to suggest a solution fit for our realities. First, the autonomous accounting system of insurers has created many problems in terms of medical insurance management system, such as inefficient administration, social unfairness in sharing the costs, retrogressive income redistribution and worsening financial gaps of insurers. Second, the insurance payments are being decided separately by workplace, job and region, bringing on differences among insurers. And the concentration of medical institutes in urban areas made the medical treatment delivery system complicated. It also generated inefficient administration and unreasonable imposition of insurance premium due to the excessive workload of estimating medical fee requirements. The solution to these problems is as follows; First, the Regional Medical Insurance Societies which consists of 373 independent unions should be integrated into one organization. The integration can secure the efficiency in management and the fairness in sharing the costs. The new organization is expected to function as a true social insurance institution which contribute to income redistribution, fair supply of medical service and removal of financial gaps among insurers. Second, in order to ease the concentration of medical institutes in cities, various kinds of tax favors and subsidies for medical facilities and instruments should be given to hospitals located in farming and fishing countries. Third, for the improvement of medical treatment delivery system, more public health centers have to be built up in areas with insufficient medical facilities. The public health centers should be able to function as a hospital with broad treatment sectors, enough medical experts and cutting-edge instruments to meet the local residents' demand for medical service. Fourth, as a means to expand the scope of insurance payment, the limit on the payment period per year should be abolished as soon as possible. The number of medical services out of the payment coverage has to be reduced and for the equity of insurant the compensation for the individual payment should be put into sweeping practice. Fifth, an appropriate medical insurance fee decision system should be set up on a realistic basis. At the same time a strict regulation has to be enforced to prevent improper medical fee requirements from hospitals. Finally, if the realization of national medical insurance of social insurance style is the ultimate goal of medical welfare policy, Korea has succeeded in expanding the number of insurant. Now it is time for us to improve the quality of the medical insurance. By doing so, we can have a national medical insurance from which all people in every walk of life can benefit.

健康保險制度의 改善에 관한 法的 考察

장욱 延世大學校 大學院 2005 국내박사

업무상 재해보상과 실손의료보험의 관계에 대한 연구 : 중복보상 문제를 중심으로

오옥진 국민대학교 법무대학원 2023 국내석사

실손의료보험은 피보험자(환자)가 실제 부담한 의료비의 일정금액을 보상하는 제3보험 상품이다. 가입자수가 4천만명에 육박하며 제2의 건강보험으로 자리매김한 실손의료보험은 장기간 손해율이 100%를 웃돌며 판매를 중지하는 보험사가 늘어나는 상황에 있다. 실손의료보험은 약관 개정 때마다 본인부담률이 높아지고 있고, 실손의료보험사는 보험금 지급심사 지침을 강화하고 소비자를 상대로 채무부존재 확인 소송을 빈번히 제기하며 실손의료보험 손해율 개선을 꾀하고 있다. 이러한 상황에서 업무상 재해로 인한 의료비에 대해서는 깊이있는 검토없이 보상처리가 이루어지면서 법률상 재해보상과의 중복보상이 만연하고, 약관 문구의 개정이나 깊이있는 연구도 이루어지지 않고 있다. 실손의료보험 약관의 보상하지 않는 사항에는 “산재보험에서 보상받는 의료비”가 명시되어 있지만, 모든 근로자가 업무상 재해를 산재보험에서 보상받는 것은 아니다. 5인 이상 사업장의 근로자는 산업재해보상보험법(이하 산재보험법)에 따라, 공무원과 군인은 각각 공무원 재해보상법과 군인 재해보상법에 따라, 사립학교 교직원은 사립학교교직원 연금법(이하 사학연금법)에 따라 재해보상을 받고, 선원과 어선원도 선원법, 어선원 및 어선 재해보상보험법에 따라 각 기관의 기금으로 재해보상을 받는다. 손해보험적 성격을 가진 실손의료보험에서 실제 수납하지 않은 업무상 재해보상 의료비는 보상제외됨이 타당할 것으로 일면 보여지나, 산재보험만을 언급한 실손의료보험 약관과 건강보험이 우선 적용되는 재해보상제도 운영절차로 인해 면책시 실무상 분쟁으로 이어지거나 보험자가 업무상 재해보상 여부를 인지하지 못한 상태에서 실손의료보험금이 지급되는 등의 문제가 발생하고 있다. 특정 직업군에만 적용되는 법률에 의거한 업무상 재해 의료비 지원의 경우에는 실손의료보험에 대한 전체 분쟁 중 차지하는 비중이 낮아 심도있는 연구가 이루어지지 않았고, 보험회사별 처리방식이 상이하여 객관적 해석의 원칙에 위배될 여지가 있다. 이에 본 연구에서는 법령에 따라 지원되는 업무상 재해 의료비에 대해서 실손의료보험 약관에 명시된 조항을 살펴보고, 보상하지 않는 사항으로 명시된 재해보상제도와 명시가 없는 재해보상제도의 법적 성격을 비교하여 동일한 보상기준 적용의 타당성에 대해 연구하였다. 이를 바탕으로 법률상 재해보상과 실손의료보험의 중복보상을 방지하기 위한 약관과 법률 개정을 제안하였다. 약관상 보상하지 않을 근거가 명백해진다 하더라도, 재해근로자가 국민건강보험이 적용된 진료비를 의료기관에 수납하고 재해보상기관에서 재해근로자의 수납금액 및 국민건강보험공단의 부담분을 사후환급하는 현 재해보상제도의 운영방식하에서는 중복보상을 방지하기가 어렵다. 실손의료보험사가 재해보상절차 진행여부, 재해보상으로 인한 환급여부를 알 수 없기 때문이다. 이에 외국의 제도를 참고하여 우리나라의 재해보상제도도 선보상 방식으로 운영될 것을 제안하는 바이다. 업무상 재해근로자의 치료를 위한 지정의료기관을 확대하고 재해보상기관에서 의료비를 직접 지불하는 방식을 통하여 실손의료보험 청구를 차단할 수 있다. 또한 국민건강보험공단 산하기관으로 실손의료보험을 편입하여 사후 정산되는 의료비에 대한 정보를 실손의료보험사가 취득하면 중복보상 방지 및 이미 지급된 보험금 중 재해보상을 받은 의료비에 대한 부당이득반환청구를 할 수 있다. 중복보상을 차단하는 것이 실손의료보험의 기본취지와 다양한 직업을 가진 가입자간 형평성에 부합할 것으로 사료된다. 이러한 제도 개선을 통하여 향후 법령 제개정으로 새로운 형태의 지원의료비가 신설될 경우에도 실손의료보험과의 중복보상이 방지될 수 있는 근간을 마련하고자 한다. Medical indemnity insurance is a insurance product that covers a certain amount of medical expenses incurred by the insured (patient). With nearly 40 million subscribers, it has become a secondary health insurance product, but the loss ratio has been exceeding 100% for a long time, and more and more insurers have stopped selling it. Deductibles are increasing with each revision of the policy, and insurers are trying to improve the loss ratio by strengthening the guidelines for underwriting claims and filing frequent lawsuits against consumers to confirm the non-existence of debt. In this situation, medical expenses caused by work-related accidents are compensated without in-depth review, leading to widespread duplication of compensation with statutory workers' compensation, and no revision or in-depth study of policy wording. Although "medical expenses compensated by worker's compensation insurance" is stated as a non-covered item in the policy, not all workers are compensated by worker's compensation insurance for work-related accidents. Workers at workplaces with five or more employees are covered under the Workers' Compensation Insurance Act, civil servants and military personnel are covered under the Civil Servants' Compensation Act and the Military Compensation Act, respectively, private school teachers are covered under the Private School Teachers' Pension Act, and seafarers and fishermen are covered under the Seafarers' Act and the Fishermen and Fishing Vessels Compensation Insurance Act. On the surface, it may seem reasonable that medical expenses for work-related accidents that have not been paid are excluded from accidental medical insurance, which has a non-life insurance nature, but due to the terms and conditions of accidental medical insurance that refer only to worker's compensation insurance and the operating procedures of work-related accidents compensation system that prioritize health insurance, problems have arisen, such as disputes in practice when indemnifying, or payment of accidental medical insurance benefits without the insurer being aware of the existence of work-related accidents. In the case of support for medical expenses for work-related accidents under laws that apply only to certain occupations, the proportion of total disputes over medical indemnity insurance is low, so in-depth research has not been conducted, and there is room for violation of the principle of objective interpretation due to different handling methods by insurance companies. In this study, we examined the provisions specified in the terms and conditions of medical indemnity insurance for medical expenses for work-related accidents supported under the law, and studied the feasibility of applying the same compensation standard by comparing the legal nature of the worker's compensation system that is specified as not compensated and the worker's compensation system that is not specified in the terms and conditions. Based on this, we proposed revisions to the terms and conditions and laws to prevent duplication of compensation for accidental injury and medical insurance. Even if the grounds for non-compensation become clear under the terms and conditions, it is difficult to prevent duplicate compensation under the current operation of the compensation system, where the injured worker pays the medical expenses covered by the National Health Insurance to the medical institution, and the compensation institution reimburses the amount paid by the injured worker and the contribution of the National Health Insurance Corporation afterwards. This is because the medical insurer does not know whether the compensation process is underway or the amount of reimbursement due to compensation. Therefore, we propose that Korea's compensation system should be operated on a trial basis by referring to foreign systems. This can be done by expanding the number of designated medical centers for the treatment of workers with work-related injuries and paying medical expenses directly from the compensation organization. In addition, by incorporating the Medical Indemnity Insurance under the National Health Insurance Service and obtaining information on medical expenses that are settled after the fact, the Medical Indemnity Insurance Company can prevent duplicate compensation and claim unjust enrichment for medical expenses that have been reimbursed out of the insurance benefits already paid. It is believed that preventing duplicate compensation will be in line with the basic purpose of medical indemnity insurance and equity among members with various occupations. Through these system improvements, we hope to lay the foundation for preventing duplication of compensation with medical indemnity insurance even if new types of supportive medical expenses are established through future legislative amendment

중국의 국민건강보험제도에 관한 연구

주옥분 전북대학교 일반대학원 2014 국내석사

From today's view of the international society, the reform of medical care system has been a focus of concern in the world. The health care system has four kinds: the national health care system, the social medical insurance system, based on the market of medical insurance and savings based health insurance. As an important part of the social security system of the medical security system, plays a vital role in promoting social stability and fairness system. In different countries, because of the different national conditions, human rights situation is different, different history and culture, formed the medical insurance system of their own. And puts forward some original views in the presence of our medical system reform problems. The health care system, not only can effectively ensure the safety of social economy, the stable development, more importantly, it is to promote social justice, an important means of building a harmonious society. This paper expounds the important several national medical insurance system and existing problems, introduces the development process China medical insurance and the current implementation of the system of medical security, and combined with the status, problem analysis, put forward to increase government financial input, expanding the coverage of such measures.

자동차보험 진료수가체계의 문제점과 개선방안

이득로 연세대학교 경제대학원 2002 국내석사

현행 우리 나라 자동차보험은 책임보험과 임의보험으로 구성되어 있으며, 책임보험의 가입은 의무화되어 있고, 종합보험도 반강제화 되어 있는 등 우리 나라 자동차보험은 운영주체가 민간임에도 불구하고 사회보험적 성격이 매우 강하다./그럼에도 불구하고 자동차보험의 진료수가 체계, 특히 진료수가 수준과 가산/율, 급여범위를 중심으로 사회보험인 건강보험제도 등과 비교할 때, 자동차보험/의 진료비가 건강보험이나 산재보험에 비해 지나치게 높은 수가를 적용하고 있/다./결과적으로 이것은 자동차보험료 인상으로 이어져 소비자의 피해로 되돌아오/고 있는 것이다. 따라서 자동차보험 진료수가 체계, 특히 진료수가 수준과 가산/율을 중심으로 건강보험제도와 비교·분석을 통하여 현행 자동차보험의 진료수/가체계의 문제점을 분석하고 이에 대한 적절한 보완대책을 마련코자 한다./이러한 필요성에 따라 자동차보험 통계자료 및 건강보험 관련 정부 발표자료/를 기본자료로 사용하여 자동차보험 진료비가 건강보험 진료비보다 높은 이유/를 분석하여 보았으며, 의료기관에 근무하는 의료전문가를 대상으로 하는 설문/조사를 병행하여 사용하였다./세부 조사내용으로 자동차보험과 건강보험의 진료수가 비교, 진료내용의 차/이 및 차등가산율 등 항목별 특성을 상호 비교·분석하여 자동차보험 환자와 /건강보험 환자의 실제내용의 차이 여부를 파악한 결과 자동차보험과 건강보험/간에는 진료내용의 차이가 거의 없으며, 다만 진료량의 차이가 있을 뿐임을 알 /수 있었다./따라서 자동차보험의 진료비를 적정수준으로 관리해야 한다는 논리가 설득력/을 얻을 수 있었으며, 자동차보험 수가 Automobile insurance in Korea can be classified into compulsory insurance /and voluntary insurance. Given the obligatory feature of compulsory /insurance and quasi-obligatory feature of voluntary insurance in Korea, /automobile insurance in our market has a conspicuous character of public /insurance, nevertheless it is operated by private insurance companies. With all this, comparing the medical fee of automobile insurance with that /of public health insurance by focusing on the level of medical fees, inclusion /rate and the scope of wage gives us a perspective that the medical fee of /automobile insurance is excessively higher than that of health insurance and /of workers compensation. Subsequently, the excessive medical fee of /automobile insurance increases premium, forcing consumers to bear /additional economic burden. The objective of this study is to outline and analyze the shortfalls of the /current medical fee system of automobile insurance and thereby come up /with appropriate supplementary measures by comparing the medical fee /system of automobile insurance with that of health insurance. /To this end, based upon statistical automobile insurance and health /insurance data released by government, the analysis of the reason behind /the excessively higher level of medical fee structure of automobile insurance /was performed in comparison with the health insurance, and questionnaires /were forwarded to the people working for the medical institutions for the /research as well. More detailed research on actual differences between the patients in /automobile insurance and those in health insurance was conducted by /comparing and analyzing medical fees and specific features including /differentiated inclusion rate.It has been turned out that there are few, if any, differences in medical /treatment between automobile insurance and health insurance, with only /some differences being found in the number of medical treatment between /the two lines.Consequently, the

보완대체의학의 보험적용을 위한 평가모형 개발에 관한 연구

김계현 연세대학교 대학원 2005 국내박사

보건의료분야에 있어서 빠르게, 많은 영향을 주고 있는 몇몇 변화 가운데 하나가 보완대체의학이다. 보완대체의학은 질병 양상의 변화, 부분적인 현대의학의 한계, 환자들의 요구 등으로 인해 국내외적으로 그 이용이 증가하고 있으며, 각 국가들은 이러한 보완대체의학에 대해 국가차원 정책을 마련하고자 노력하고 있다. 현재 우리나라의 상황에서 보완대체의학과 관련된 가장 중요한 문제는 난립하고 있는 보완대체의학의 현황을 파악하여, 각각의 안전성과 유효성의 정도를 검증하고, 안전성과 유효성이 검증된 보완대체의학은 제도권 안에 포함시켜 국가차원의 관리ㆍ감독을 해야 한다는 점이다.이러한 점에 착안하여 본 연구는 보완대체의학에 보험제도의 원리를 결합하여 현존하는 보험제도상 나타날 수 있는 보완대체의학의 유형을 예측하고, 보완대체의학과 보험제도와의 합리적인 결합을 위한 보완대체의학의 평가 및 검증방법을 모색하여, 보완대체의학의 보험적용을 위한 평가기전을 개발하고자 하였다.세부적으로는 먼저 우리나라의 의학 체계와 관련된 평가의 방법을 검토하여 보완대체의학의 평가에 활용될 수 있는 평가방법을 살펴보았다. 즉 우리나라의 의학체계를 한국적 전통의학, 정통의학, 보완대체의학으로 구분하고, 각 의학체계의 평가에 활용될 수 있는 방법들을 살펴보았다. 또한 이러한 방법들을 평가의 기준과 방법을 중심으로 역사적 평가방법과 과학적 평가방법, 경제적 평가방법으로 분류하였다. 이러한 기준에 따라 우리나라에 현존하거나 새로 유입될 보완대체의학의 경우 주로 정통의학의 평가방법을 적용할 수 있고, 일부 전통의학적 평가방법을 적용할 수 있으나 이러한 평가방법이 보완대체의학의 특수성을 반영하기에는 한계가 있음을 살펴볼 수 있었다.즉 보완대체의학의 평가방법을 고려함에 있어서는 보완대체의학 자체의 안전성과 유효성을 평가하는 방법과 보험급여 적용을 위한 평가방법은 상이할 수 있다고 보았다. 이로인해 본 연구에서는 보완대체의학의 보다 효과적이고 체계적인 검증을 위해 국가차원의 사전평가 프로그램을 마련하여 보완대체의학의 현황을 파악하고, 보완대체의학의 특수성을 반영한 안전성과 유효성의 검증결과들을 데이터베이스화하여야 하며, 이를 위한 관리체계를 구축할 것을 제안하였다.특히 사전평가에 있어서는 Stufflebeam D의 ‘CIPP 평가 모형’을 활용하여 상황(Context), 투입(Input), 과정(Process), 산출(Product)의 영역을 중심으로 사전 평가 모형의 틀을 구축하고, 보완대체의학의 특성 및 보험 적용시 고려하여야 할 요소와 우리나라의 의료적 현실을 반영하여 평가항목을 설정하였으며, 이를 바탕으로 보완대체의학의 보험적용을 위한 의사결정과정 모형을 개발하고자 하였다.또한 보완대체의학의 보험적용과 관련하여서는 안전성과 유효성이 검증된 의료인에 의한 행위로 제한하여야 하고, 현재 우리나라에서 형성된 의료행위의 조건을 모두 충족하여야 하며, 국민건강보험법상의 요양급여 대상이 되기 위한 평가과정과 동일한 기준이 적용되어 보험제도에 흡수되어야 한다고 보았다.또한 국가 차원에서 보다 효율적으로 보완대체의학을 관리ㆍ감독을 위해서는 관련 법률을 정비하고, 보완대체의학을 보다 체계적으로 검증하고, 관련 정보를 효율적으로 제공 할 수 있는 독립기구의 설립도 고려되어야 한다. The complementary and alternative medicine (CAM) is one of the changes which have exerted the rapid and strong influence on the field of health care. As CAM has been used increasingly at home and abroad owing to the change of disease aspects, the partial limits of modern medicine, and the requests of patients, each country tries to prepare the national-dimensional policy on such CAM. In the present situation of our country, the crucial problems related to such CAM are to identify the current state of disorderly and confused CAM, and verify the safety and effectiveness of each CAM, and include the CAM, which is verified to be safe and effective, into the institutionalized system for the national-dimensional management and supervision.In consideration of this point, the purpose of this study was to combine CAM with the principle of insurance system, and so predict the types of CAM which could be shown on the existing insurance system, and devise the evaluation and verification method of CAM for the rational combination of CAM and the insurance system, and so develop the evaluation mechanism for the insurance application of CAM.In details, first this study reviewed the evaluation method related to the medical system of our country, and so examined the evaluation method which could be utilized to evaluate CAM. That is, this study classified the medical system of our country into the Korean traditional medicine, the allopathic medicine, and CAM, and so examined the evaluation methods which could be utilized to evaluate each medical system. Also, this study classified these methods into the historical evaluation method, the scientific evaluation method, and the economic evaluation method on the basis of the evaluation criteria and methods. According to these criteria, mainly the evaluation method of allopathic medicine or partially the evaluation method of traditional method could be applied to the CAM which was existing or would be newly introduced, but these evaluation methods had the limitation to reflect the particularity of CAM.That is, according to the results of this study, in considering the evaluation method of CAM, the method to evaluate the safety and effectiveness of CAM itself and the method to evaluate the insurance benefit application of CAM could be different. For this reason, in order to verify CAM more effectively and systematically, this study proposed to prepare the prior evaluation program of national dimension and so identify the current state of CAM, and establish the database on the verification results of safety and effectiveness which reflected the particularity of CAM, and so construct the management system for such database.Especially, this study utilized D. Stufflebeam''s ''CIPP Evaluation Model'' in the prior evaluation, and so constructed the framework of prior evaluation model by focusing on the domain of context, input, process, and product, and set up the features of CAM, the elements to be considered in the insurance application of CAM, and the evaluation items to reflect the medical reality of our country, and then, on the basis of this, develop the decision-making process model for the insurance application of CAM.Also, the insurance application of CAM should be limited to the medical treatments by the medical practitioners who are verified to be safe and effective, and should satisfy all the conditions of medical treatments which have been formed in our country. And, the same criteria as the evaluation process for the object of care benefit under National Health Insurance Act should be applied to CAM, in order to incorporate the CAM into the insurance system.Also, in order to manage and supervise CAM more efficiently in the national dimension, the independent organization should be established to arrange the related laws, and verify CAM more systematically, and provide the related information more efficiently.

醫療保險 藥劑費 決定에 미치는 要因分析

홍월난 漢陽大學校 行政大學院 1995 국내석사