주요국의 초음파검사 시행현황과 질 확보방안

정설희 ( Seol Hee Chung ),이해진 ( Hye Jin Lee ),김현상 ( Han Sang Kim ),오주연 ( Ju Yeon Oh ) 한국보건행정학회 2014 보건행정학회지 Vol.24 No.2

In accordance with the government`s plan to expand the national health insurance (NHI) coverage for severe diseases such as cancer, heart disease, cerebrovascular disease, and rare and incurable disease, the diagnostic ultrasound services have been covered by NHI from October 1, 2013. The quality is very important factor in providing diagnostic services because they influence on the diagnosis, treatment, and outcome of diseases. In particular, equipments and health care providers plays an important role in providing qualitative services. The purpose of this paper is to examine the major feature of ultrasound services covered by health security system and to review quality assurance policies in other countries such as Australia, Japan, the USA, and Canada. In addition, we assessed the implication of those policies. We especially put emphasis on the types and qualifications of healthcare professionals and measures to manage equipments. All countries have reviewed on policies to promote the quality such as educational requirements of professionals or restrictions on the duration of equipment usage. Various measures should be implemented to assure the qualitative ultrasound service.

임상연구의 통상진료비용에 대한 건강보험 적용 타당성

정설희 ( Chung Seol Hee ),조재영 ( Cho Jae Young ) 한국보건경제정책학회 2017 보건경제와 정책연구 Vol.23 No.2

본 연구는 임상연구의 개념과 유형, 외국의 의료보장 적용현황, 국내 임상연구 수행 현황을 확인하고, 이를 바탕으로 임상연구 관련 통상진료비용(routine care cost)의 건강보험 적용 타당성을 고찰하고 건강보험 적용을 위한 정책방향을 설정하고자 하였다. 본 연구를 위하여 국내외 기존 문헌 고찰, 임상연구 수행기관을 대상으로 설문조사를 시행하고, 전문가의 자문을 거쳤다. 연구결과, 모든 환자에 대한 보편적 의료보장 원칙 적용, 환자의 치료기회 확대, 급여기준 개선으로 인한 건강보험 재정지출 절감 및 국민 건강증진, 제도운영의 효율성 개선 측면에서 건강보험 적용이 필요하다고 판단된다. 통상진료비용은 건강보험법령에서 정한 요양급여비용으로 정의하고, 대상 임상연구의 범위는 다음과 같은 원칙 하에 설정될 필요가 있다. 첫째, 환 자 치료 또는 진료과정 상의 개선을 위해 통상 진료가 발생하는 경우에 한해 적용해야 한다. 연구만을 목적으로 수행되는 추가적인 진료 또는 건강한 사람을 대상으로 하는 경우, 연구 및 관리 비용 등은 제외되어야 할 것이다. 둘째, 피험자의 안전이 확보된 임상연구에 한해 적용해야 하며, 이를 위해 연구 심의절차와 모니터링 절차가 마련되어야 할 것이다. 셋째, 산업계의 이익은 배제하고 학술 목적 연구에 한해 적용해야 한다. 즉 제품 개발을 위한 연구나 제품의 시판후조사(PMS) 연구는 지원 대상에서 제외하고, 순수 학술목적의 연구자주도임상연구를 중심으로 지원하도록 한다. 여기에는 주로 임상적 유효성, 안전성이 이미 검증된 제품을 대상으로 치료적, 경제적 가치를 평가하거나 장기적 이상반응을 조사하는 등의 연구가 해당된다. 이러한 근거는 장기적으로 건강보험 급여 기준 개선에 활용함으로써 건강보험 재정의 비용효과적 사용에 기여할 수 있을 것이다. The routine care provided to the participants in the clinical trials has not been covered by National Health Insurance (NHI) in Korea. There have been requests for covering routine care costs associated with care for participants in clinical trials by NHI. This study was performed to secure rationale and define the principles and prerequisites to cover routine care costs of the clinical trials by NHI. For this purpose we studied foreign cases, reviewed literature, surveyed the medical institutions performing clinical trials and consulted experts. We recommend that the routine care costs have to be covered by National Health Insurance for expanding opportunities to care, quality assurance of the care provided to the participants, reduction of health care costs in the NHI, improving of patients` health, and increasing operational efficiency of the NHI. “Routine care” includes the items or services covered by NHI when patients need medical care. The new system should be designed based on the following principles. First, NHI has to cover the routine care costs needed to treat patients. Second, the benefit coverage of the NHI has to be applied to clinical trials which secure patients` safety. Third, the clinical trials for the academic research have to be covered by NHI. Fourth, management systems are needed which evaluate ethical issues, provide related information and monitor the process and results of the clinical trials covered by NHI. Finally, the existing systems such as Coverage with Evidence Development have to be taken into consideration

DRG 지불제도가 재원일수와 퇴원 후 외래방문일수에 미치는 영향: 2004-2007년도 제왕절개술을 중심으로

손창우,정설희,이선주,권순만,Shon, Chang-Woo,Chung, Seol-Hee,Yi, Seon-Ju,Kwon, Soon-Man 대한예방의학회 2011 예방의학회지 Vol.44 No.1

Objectives: The purpose of this study was to examine the impact of Diagnosis-Related Group (DRG)-based payment on the length of stay and the number of outpatient visits after discharge in for patients who had undergone caesarean section. Methods: This study used the health insurance data of the patients in health care facilities that were paid by the Fee-For-Service (FFS) in 2001-2004, but they participated in the DRG payment system in 2005-2007. In order to examine the net effects of DRG payment, the Difference-In-Differences (DID) method was adopted to observe the difference in health care utilization before and after the participation in the DRG payment system. The dependent variables of the regression model were the length of stay and number of outpatient visits after discharge, and the explanatory variables included the characteristics of the patients and the health care facilities. Results: The length of stay in DRG-paid health care facilities was greater than that in the FFS-paid ones. Yet, DRG payment has no statistically significant effect on the number of outpatient visits after discharge. Conclusions: The results of this study that DRG payment was not effective in reducing the length of stay can be related to the nature of voluntary participation in the DRG system. Only those health care facilities that are already efficient in terms of the length of stay or that can benefit from the DRG payment may decide to participate in the program.

대만 중의 건강보험의 체계와 서비스 질 향상 정책

김동수,권수현,정설희,안보령,임병묵,Kim, Dongsu,Kwon, Soo Hyun,Chung, Seol Hee,Ahn, Bo Ryung,Lim, Byungmook 대한예방한의학회 2016 대한예방한의학회지 Vol.20 No.2

Backgrounds : Taiwan has similar national health insurance (NHI) system for traditional medicine with South Korea. Recently, new quality improvement policies for traditional medicine is being attempted in Taiwan. Objectives : This study aimed to review the Taiwanese NHI system for Chinese Medicine (CM) and introduce quality improvement policies. Methods : Research articles, reports, government publications and year books which handled traditional medicine system and NHI system in Taiwan were searched and collected. The authors analyzed and summarized the contents in a qualitative manner. Results : In Taiwanese NHI system, CM procedures and medication for outpatients are reimbursed through a mix of fee-for-service and global budget payment system. CM shares 4% of total expenditure of NHI in Taiwan. Mostly, the expenses for procedures are reimbursed regardless of disease type, however, in the specialized program for quality improvement, CM doctors have to comply with standard operating procedures (SOPs). Conclusions : Taiwanese NHI system implemented SOP-based new reimbursement system for CM. Yet, the scientific evidences for SOPs are not sufficient, it can be useful references when we develope disease related reimbursement system for Korean Medicine in South Korea.

응급의료센터를 보유한 의료기관 입원 중 응급실경유입원 관련 요인

나백주 ( Baeg Ju Na ),정설희 ( Seol Hee Chung ),이선경 ( Sun Kyung Lee ),오경희 ( Kyung Hee Oh ),김건엽 ( Keon Yeop Kim ) 한국보건행정학회 2009 보건행정학회지 Vol.19 No.2

Objectives: The purpose of this study is to analyze the proportion of admission via the emergency room(the rest is ER) in an emergency medical center and to examine the factors related to admission. Methods: This study used 2005 National Health Insurance claims data for admitted patients of 112 hospitals having emergency medical centers in Korea. The study sample had 2,335,610 patients. The data was classified into emergency admission and non-emergency admission. To investigate the factors affecting the type of admission, the following were included as independent variables: type of health assurance_(national health insurance beneficiaries or medical aid beneficiaries), demographic characteristics_ (sex, age), cause of admission_ (disease or injury), whether an operation was performed or not, DRG severity level, the number of beds, and the location of the hospital. Data were analyzed using the Chi?square test for the differences in emergency admission rates for each variables, and multiple logistic regression analysis was used for identifying the factors affecting admission type. Results: The proportion of admission via the ER accounted for 40.6% of the total admission among hospitals having emergency medical centers. The risk of admission via ER was relatively high for patients who were male, the aged, the injured, the surgical patients, the patients having more severe symptoms, and the patients admitted the hospitals located in metropolitan areas, and the patients admitted the hospitals having 300?699 beds. Medical aid patients were more likely admitted through the emergency room than health insurance patients after other variables ware adjusted. Conclusions and Discussion: We analyzed the proportion of admission via the ER for the total admission rate of hospitals having an emergency medical center in Korea. And we explored the factors related to admission via the ER. This proportion may be used as an indicator of the adequacy of medical utilization or low accessibility to hospitals of patients with low socioeconomic status.

의료보장제도 운영에 있어서 전략적 구매의 개념과 한국 제도에의 적용

김덕호(Duck-Ho Kim),정설희(Seol Hee Chung) 한국콘텐츠학회 2018 한국콘텐츠학회논문지 Vol.18 No.1

재정의 지속가능성 확보는 보편적 의료보장(UHC)을 달성하기 위해 필수적이며, 전 세계적으로 재정관리체계 구성요소 중 하나인 전략적 구매기능에 관심이 높아지고 있다. 본 연구에서는 전략적 구매의 개념과 기능을 고찰하고, 한국 건강보험제도에 있어서의 구매기능과 관련 기관을 Preker(2005)가 제시한 전략적 구매 모형에 근거하여 검토하였다. 이를 위하여 관련 문헌을 고찰하였다. 전략적 구매는 주어진 예산의 범위 내에서 국민이 필요로 하는 보건의료서비스를 제공하기 위한 전략적 활동으로 정의된다. 구매관리자는 정부 혹은 국민들을 대신하여 구매 활동을 수행하며, 정부, 구매자, 의료공급자의 관계는 주인-대리인 이론으로 설명될 수 있다. 우리나라에서의 ‘구매’는 ‘한정된 재정 내에서 국민이 필요로 하는 보건의료를 제공하기 위한 전략적 활동으로 급여 범위와 대상 설정, 상급종합병원 지정이나 정보 공개 등 양질의 의료서비스 공급자 선정 활동, 급여기준과 가격 설정, 진료비 지불방법의 설계와 운영, 심사와 평가, 모니터링 활동을 포함’하는 것으로 설명할 수 있다. 건강보험심사평가원과 국민건강보험공단이 정부의 위임을 받아 주된 구매활동을 수행하며, 의료기관평가인증원과 한국보건의료연구원 등이 일부 역할을 담당하고 있다. Many countries have tried to reform financing systems toward UHC and paid attention to the function of strategic purchasing. This study was performed to examine theoretical foundations and the function of strategic purchasing. And we examined the functions of strategic purchasing in Korea based on the framework proposed by Preker(2005). For this purpose, we reviewed literature related to purchasing. we defined the strategic purchasing as strategic activities to provide health care services people need within a given budget, which is carried out by certain organizations, purchasing organizations. These activities include selecting appropriate providers, designing and operating the payment system, setting the price, and determining the target populations and their needs etc. The relationships among government, purchasers and healthcare providers can be explained by the principal-agent theory. In addition to Preker’s framework, we emphasized the importance of the infrastructure such as decision making support systems, information systems, health care resource management systems, or expenditure monitoring systems. The National Health Insurance Service and the Health Insurance Review & Assessment Service play major roles in performing strategic purchasing.

혁신의료기술의 확산과 보건의료제도: 한국의 로봇보조수술 사례

문경준 ( Kyeongjun Moon ),권오탁 ( Ohtak Kwon ),정설희 ( Seol-hee Chung ) 한국보건경제정책학회 2022 보건경제와 정책연구 Vol.28 No.1

이 논문은 로봇보조수술 사례를 통해 우리나라에서 혁신의료기술이 도입되고 의료보장제도인 급여에 포함되기까지의 과정 전반에 걸쳐 보건의료 제도적 측면에서의 현안과 과제를 파악하기 위해 시행되었다. 이를 위해 신의료기술의 도입 체계를 고찰하고, 로봇보조수술 시행현황을 각 단계별로 분석하였으며, 혁신의료기술의 도입 및 시행 과정에서의 정책의제를 분석하였다. 이를 위해 관련 법령, 국내외 기존 문헌 고찰을 시행하였다. 또한 로봇보조수술의 시행현황을 분석하기 위하여 건강보험청구자료, 의료자원 신고자료, 의료기관을 대상으로 한 실태조사 자료, 의료장비 제조회사로부터 확보한 자료를 이용하였다. 신의료기술이 의료현장에 사용될 때는 신의료기술평가, 급여 결정, 수가 설정, 사후관리 단계를 거친다. 로봇보조수술은 2006년도에 비급여 대상 항목으로 지정되어 시행되기 시작하였으며, 2018년도에 총 21,761 건의 수술이 시행되었다. 일부 수술은 안전성과 유효성에 대한 근거가 부족하였다. 적응증별 로봇보조수술의 시행 건수의 비중은 적응증에 따라 0.9%에서 66.5%로 파악되었다. 로봇보조수술의 진료비는 적응증에 따라 개복수술 진료비에 비해 1.28~7.85배 높았으며, 복강경 수술 진료비에 비해서는 1.15~3.30배 높은 것으로 나타났다. 현재 시행되고 있는 로봇보조수술이 사용되는 시술의 종류를 건강보험 행위 급여·비급여 목록표의 분류번호를 기준으로 하면 총 45개 이상의 수술에서 시행되고 있었다. 로봇보조수술의 사례 분석을 통해 신의료기술의 의료보장 적용을 위해서는 지속적인 신의료기술 평가 수행과 평가 결과에 대한 엄격한 해석, 급여 적용 시 명확한 급여기준의 설정과 가격산정, 지속적인 사후관리 등 도입부터 시행에 이르는 전 단계에 걸친 관리가 필요함을 제시하였다. This article aimed to identify the issues and challenges to be taken into account when introducing innovative health technologies into Korea’s NHI coverage in the aspects of regulatory framework. focused on the analysis of the robot-assisted surgery(RAS) use. We examined each stage of the diffusion process of new healthcare technologies in policy terms. And we analyzed the implementation status of RAS and drew challenges faced by the healthcare system to respond to the diffusion of cutting-edge technology. For this, we reviewed related laws and regulations, reports, and articles. The implementation status of RAS was analyzed using the Korean National Health Insurance Claims Data, medical device status data, the data of the Korea Case Payment System, survey data, and statistics obtained from a medical device company. In Korea, the new technologies should be taken the process of nHTA, coverage determination, price setting, and post-management to be used in clinical care. RAS was designated as a non-benefit service in 2006 and 21,761 RASs were implemented as of 2018. Some RASs didn’t have sufficient evidence on the safety and clinical effectiveness. The proportion of robotic methods of the surgery is 0.9% to 66.5% depending on the indications. The cost of RAS was 1.15~3.30 times higher than the cost of laparoscopic surgery and 1.28~7.85 times higher than the cost of open surgery. The RAS was performed in over 45 operations. We could conclude that the management of new technologies has to be implemented strictly ranging from approval to using them are needed.

보건분야 우선순위 설정에 대한 외국 사례 비교 및 정책적 시사점

송현종 ( Hyun Jong Song ),강민선 ( Min Sun Kang ),조수진 ( Su Jin Cho ),정설희 ( Seol Hee Chung ),오주연 ( Ju Yeon Oh ) 한국보건경제정책학회(구 한국보건경제학회) 2008 보건경제와 정책연구 Vol.14 No.1

보건의료에 대한 수요 및 요구는 가용한 자원의 용량을 초과하기 때문에 이를 효율적으로 할당하여 사용하는 것은 전세계 모든 국가의 과제라고 할 수 있다. 따라서 우선순위를 설정하여 자원을 배분하여야 하는 선택이 필요하다. 1980년대 후반부터 유럽국가를 중심으로 보건의료 분야에서 우선순위 설정에 대한 논의가 시작되었으나 우리나라의 경우 이에 대한 연구 및 문제제기가 부족하였던 실정이다. 본 연구에서는 외국의 보건분야 우선순위 설정 사례를 분석하고 우리나라에 주는 시사점을 도출하였다. 본 연구의 분석 대상 국가에서는 증가하는 보건의료비가 국가 전체 재정에 영향을 주거나 의료보장 서비스의 제한에 대한 요구가 표출되어 우선순위에 대한 논의를 시작하였다. 이러한 우선순위는 임상적 기준과 사회적 기준을 동시에 고려하여 결정되는데 질병의 위중도, 비용-효과성, 개인의 책임 등이 기준으로 사용되었다. 또한 중앙정부 및 지방정부 차원에서 설정되었고 개별 병원과 같은 특정기관에서 우선순위를 설정하기도 하였다. 많은 국가에서 역학 및 경제학적 접근방법을 명시적 우선순위 설정방법으로 사용하고 있으며 최근 들어 의료기술평가가 활용되고 있다. 아울러 대중의 참여가 매우 중요하게 논의되었다. 우리나라에서 우선순위를 설정할 때, 명확하고 합의할 수 있는 원칙과 가치를 만드는 것이 매우 중요한데 이를 위해서 각계의 의견 수렴 과정을 포함하여야 한다. Efficient resource allocation is one of major challenge among the all nations because health care demand usually exceeds the available resources. Therefore, rationing and priority setting are necessary to allocate scarce resources effectively. However, discussions and studies about priority setting regarding health care are insufficient in Korea while rationing and priority setting in health care has been discussed among the European countries since the late 1980`s. This paper offers the comprehensive analysis of rationing and priority setting in major foreign countries and ultimately drives suggestions for Korea. The health care cost containment and the limitation on health care coverage are major motivation to start discussions about prioritization among the foreign countries. Those prioritizations are based on both clinical standards and social standards including disease severity, cost effectiveness, individual responsibility, etc. The levels of prioritization are federal governments, local governments, and individual organizations such as hospitals. Epidemiological and economical approaches are used as prioritization methods and recently medical technology evaluation is used for the prioritization in many countries. The participation of the general public is getting important in the priority setting at the same time. In conclusion, various stake holders and interest groups should be included for the priority setting in Korea to develop clear standards by common consent.

일부 병원에서의 입원비 본인부담양상

신영전,유원섭,하헌영,정설희 한양대학교 의과대학 2000 한양의대 학술지 Vol.20 No.1

The purpose of this study was to estimate the proportion of user charges out of total treatment costs and to investigate the occuring status of the charge of non-benefit service. The data were collected from 6 hospitals in 3 cities (Seoul 2, Incheon 3, Shihung 1), which containing 1,752 discharge-bills of discharged patients insured by health insurance. The data were analyzed after standardization of the items of non-benefit services. The result are as follows; 1. the average percent of the cost-sharing of discharged patients was 38.1%(benefit : 15.5%, non-benefit : 22.6%) and the proportion of the cost-sharing due to non-benefit services was greater than that due to benefit services. 2. The occurrence rate and the occurred number of non-benefit services were different among hospitals and showed characteristic occurrence rate in individual hospitals. 3. In acute appendicitis, the characteristics of the occurrence rate and the occurred number of non-benefit services by individual hospitals was similar to those of hospitals. It suggest that the hospitals intentionally applied non-benefit item to patients in order to increase their profit. These findings suggest that the burden of cost-sharing is still high especially due to non-benefit services, so it is necessary to extend the coverage of insurance benefits and to develop management system for the appliance of non-benefit services. Regarding the discharge-bill, all service charges should be included in the bill.