비급여를 포함한 상병‧수술별 환자부담 진료비 추정 연구 : 경피적 대동맥판 삽입술(TAVI) 사례

김하윤,박보람,장종원 한국보건경제정책학회 2023 보건경제와 정책연구 Vol.29 No.4

It is very difficult to predict in advance the costs that patients pay for receiving medical services. The absence of useful information for patients, such as medical costs and safety, is causing various problems from a policy and economic perspective. Accordingly, in order for patients to use reasonable medical services at an appropriate cost, it is important to calculate and provide the total medical costs incurred per disease or surgery using comprehensive information that can be provided. Therefore, through the case of Transcatheter Aortic Valve Implantation(TAVI), which is burdensome for patients with severe aortic valve stenosis, the total medical costs and composition status including non-benefits medical costs were analyzed. First, the criteria and grounds for selecting disease and surgery to be analyzed were reviewed, and episode of care were defined. Second, the average medical costs including insurer's contributions, co-payments, non-benefits, and the composition of medical treatment items were analyzed. In addition, a comparison was presented between the total medical costs considering age group and comorbidities and the similar surgeries. This study used actual medical data to define episode of care and estimate total medical costs, to provide basic data for the composition of total medical costs, including non-benefits medical costs. In the future, there is a need for additional analysis to establish sufficient basis for the definition of episode of care and data sources, and to expand the target.

호스피스케어와 전통적 의료서비스 이용간의 사망전 의료비용 비교

최귀선,유창훈,이경희,김창엽,허대석,윤영호 한국보건행정학회 2005 보건행정학회지 Vol.15 No.2

The aim of this study was to compare medical cost of hospice care and that of conventional care during the last year of life, and identify factors that influenced the cost. From January to August 2003 592 terminal cancer patients receiving care from 5 hospice care units and 2 hospice care teams in general hospitals were enrolled to case group. Two hundreds and seventy two terminal cancer patients receiving conventional care from 7 general hospitals were enrolled to hospital‐based control group, and 1,636 terminal cancer patients from 122 general hospitals located in same regions with the 7 hospitals were enrolled to community‐based control. We used characteristics and medical cost from data of National Health Insurance Cooperation. Total medical cost per beneficiary in cases was about 10 millions won, 14.5 millions in hospital‐based controls and 11.1 millions in community‐based controls. The hospice care saved 45% over the last year of life compared with hospital‐based controls (p<0.0001). Saving of inpatient cost account for approximately 80% of saving per beneficiary. Hospice care saved 29% of medical cost per hospitalization day compared with hospital‐based controls and 17% compared with community‐based controls (p<0.0001). Multiple regression analyses showed that hospice care significantly saved the medical cost. This study suggest that hospice care save medical cost compared with hospital‐based control and community‐based control. Most of saving of inpatient cost account for approximately 80% of saving of medical cost.

국민건강보험 요양급여 기준에 관한 법적 고찰

권오탁 한국의료법학회 2023 한국의료법학회지 Vol.31 No.2

Korea, which chose national health insurance as a method of social security, made all citizens insured, designated all medical institutions as health care institutions, compensated costs through health insurance, and divided medical care benefits into covered and non-coverage benefits. As a result, the following issues are being raised regarding medical care benefit standards. First, the standards for medical care benefits are uniform and cost review is arbitrary. However, universality of medical care benefits is recognized as a result of the collective intelligence of experts with medical expertise. In addition, which of the various treatment methods will be compensated by health insurance is not a medical issue, but a matter of policy choice based on expertise, universality, and financial conditions, and cost review based on those standards cannot be considered arbitrary. Second, medical technology prior to new medical technology evaluation under the National Health Insurance Act can also be used for non-coverage benefits purposes. First of all, all medical services used in clinical settings must have proven safety and effectiveness, and under the premise of safety and effectiveness, medical care benefits and non-coverage benefits are distinguished depending on the degree of cost-effectiveness proven. However, due to the discrepancy between the development of science and technology and the timing of applying medical care benefits, the timing of use of new, unproven medical technology may become an issue. As a result, except for pharmaceuticals, medical practices and treatment materials are ultimately verified for safety and effectiveness through evaluation of new medical technologies. However, the relevant regulations are unclear and need to be clearly revised. Third, after the application of ideologically expensive drugs to health insurance, controversy may arise regarding the scope of coverage of National Health Insurance, a social insurance policy. Considering the development of science and technology and the public's health needs, a new agreement on the minimum guarantee of social insurance is needed. Therefore, for the sustainability of health insurance, it is time to publicize and reach a social consensus on the plan to secure health insurance finances, the scope and target of compensation for medical care benefits, and the principles of applying medical care benefits for new future medical technologies. 「국민건강보험법」을 통해 국민에게 발생한 건강문제를 해결하는 우리나라는 의료기관에서 제공될 수 있는 진료행위의 내용을 요양급여와 비급여로 구분하고 요양급여 비용을 건강보험을 통해 보상하고 있다. 따라서 의료기관에게는 진료기준이 되고 비용보상 시에는 심사기준이 되는 요양급여 기준과 관련해서 다음과 같은 문제가 제기될 수 있다. 첫째, 요양급여 기준이 제한적‧획일적이고 비용심사가 자의적이라는 문제 제기가 가능하다. 그러나 요양급여 기준은 의학분야의 전문가 집단이 숙의 과정을 통해 합의한 산물이기 때문에 의학적 타당성을 인정할 수 있다. 또한 다양한 의학적인 방법 중 어떤 것을 비용 보상의 대상으로 할지는 의학적인 영역을 넘어서 전문성과 보편성 그리고 재정여건에 기초한 정책적 선택의 문제이다. 따라서 그 기준에 따른 비용심사를 자의적이라고 볼 수 없다. 둘째, 구조적으로 현행「국민건강보험법」상 신의료기술을 비급여로 사용할 수 있는지에 관한 것이다. 원칙적으로 임상현장에서 사용되는 모든 의료서비스는 안전성과 유효성이 검증된 것이어야 한다. 다만 과학기술의 발전과 요양급여 적용 여부에 소요되는 시간의 문제로 인해 안전성과 유효성의 검증 시점이 중요한 쟁점이 될 수 있다. 결과적으로 의약품을 제외한 의료행위와 치료재료는 신의료기술 평가를 통해 최종적으로 안전성과 유효성이 검증된다. 그러나 현행 법률이 명확하지 않아 그 시점에 대한 논란이 발생할 수 있어 관련 규정을 보다 명확하게 개정할 필요가 있다. 셋째, 이념적으로 고가의 의약품이 요양급여로 등재되면서 사회보험인 국민건강보험의 보장범위에 대한 논란이 발생할 수 있다. 과학기술의 발전 속도와 국민의 건강에 대한 요구가 커진 상황을 고려하면 재정여건에 맞는 수준의 보상이라는 사회보험의 원칙에 대한 새로운 합의가 필요한 시점이다. 따라서 구체적으로 건강보험 재정안정화를 위해 건강보험재정확보 방안, 요양급여 비용 보상의 범위와 대상, 미래 신의료기술에 대한 요양급여 적용 원칙 등의 문제를 공론화하고 사회적 합의를 이끌어 내야한다.

호스피스 케어를 위해 입원한 말기 암 환자의 사망직전 의료비용 실태 조사

유상연,이혜리,이용제,안미홍,염창환,Yoo, Sang-Yeon,Lee, Hye-Ree,Lee, Yong-Je,Ahn, Mi-Hong,Yeom, Chang-Hwan 한국호스피스완화의료학회 2002 한국호스피스.완화의료학회지 Vol.5 No.2

배경 : 세계적으로 암의 발생률과 사망률은 증가하는 추세로, 그로 인한 의료비 상승의 문제로 국가 정책의 필요성이 대두되고 있다. 이에 저자 등은 호스피스 케어를 위해 입원한 말기 암 환자들의 의료비용 실태를 조사하고 이와 관련된 요인도 함께 살펴보아 불필요한 의료비용 부분의 효과적 감소에 도움이 되고자 하였다. 방법 : 2000년 7월 1일부터 2002년 6월 30일 사이에 경기도 고양시에 소재한 모 병원 가정의학과에 말기 암으로 입원하여 사망한 환자 259명을 대상으로 인구통계학적 자료 암의 기왕력, 임상소견, 의료비용을 조사하였다. 의료비용은 환자의 사망직전 입원 당시의 원무과 계산서를 근거로 세부 항목을 조사하였다. 인구통계학적 특성, 암의 기왕력, 임상 소견과 평균 의료비용과의 상관관계를 ANOVA로 조사하였다. 결과 : 말기 암 환자 259명중 남자가 135명(52.1%), 여자가 124명(47.9%)이었으며, 암의 종류는 위암이(58명, 22.4%) 제일 많았다. 입원 당시의 임상소견은 식욕부진이 227명(87.6%), 통증이 199명(76.8%), 오심 구토가 152명(58.7%) 순으로 높게 나타났다. 총 의료비용은 740,628,045원이었으며 환자 1인당 평균 의료비용은 $285,968{\pm}3,070,272$원이었다. 총 의료비용 중에서 주사료가 237,038,259원(32.0%)로 가장 많았고 병실료가 206,416,669원(27.9%), 검사료(임상병리 검사료와 진단 방사선료)가 103,417,747원(14.0%) 순이었다. 평균 의료비용은 주사료, 치료방사선료, 병실료 순으로 높았다. 인구통계학적 특성, 암의 기왕력, 임상소견의 항목 중 통증만 유일하게 평균 의료비용과 상관관계가 있었다(P<0.05). 결론 : 호스피스 케어를 받는 말기 암 입원 환자들에서 불필요한 마약성 진통제 등 주사 투여를 가능하면 줄이고 가정 내 호스피스를 활성화하고 과도한 검사를 줄임으로써 보다 더 효과적인 비용 절감을 도모할 수 있을 것으로 보인다. Purpose : Death due to cancer has been continuously increasing, therefore cancer is the first in the cause of death now. A national policy for the elevation of medical costs in cancer patients is necessary, therefore, we searched for the medical costs and its related factors in terminal cancer patients for the effective reduction of the medical costs. Methods : We reviewed the medical records of 259 hospitalized terminal cancer patients who had died during the period of July 1, 2000 to June 30, 2002. History of cancer included type of cancer, type of past treatment, existence of metastasis. Clinical manifestation was examined and medical costs on last admission was categorized based on the account of charges of the department of patient affair on the last hospitalization. For analysis of factors related with medical costs, ANOVA was used. Results : Of the 259 patients, the number of male was 135 cases (52.1%), and the female, 124 cases (47.9%). The most frequent type of cancer was stomach (21.9%) cancer. Of the clinical manifestation, anorexia (87.6%) was the most frequent manifestation. Total medical costs was 740,628,045won, the mean costs was $285,968{\pm}3,070,272won$. The frequent category of medical costs was injection (32.0%), medical accommodation (27.9%), examination (14.0%), in order. The only factor related with mean medical costs was pain (P<0.05). Conclusion : If unnecessary injection of opioid analgesics is reduced, hospice care at home is activated and excessive examination is reduced In terminal cancer inpatients, it will be possible to reduce the medical costs in terminal cancer patients more effectively.

한 종합병원의 포괄수가제 실시 전후 수정체 수술환자의 의료서비스 및 진료비 비교분석

이미림 ( Mi Rim Lee ),이용환 ( Yong Hwan Lee ),고광욱 ( Kwang Wook Koh ) 한국병원경영학회 2005 병원경영학회지 Vol.10 No.1

The purpose of this study was to make an analysis of the impact of the DRG payment system on medical care pattern and cost of cataract surgery in a general hospital. The subjects were 173 patients whose DRG severity grade was zero, selected from among the hospitalized who underwent cataract surgery before and after the joining to the demonstrational operation of the third year DRG payment system. Their medical records and the details of their medical hills were examined to find out the length of hospital stay, medical care pattern provided to them, the cost of medical care, and the quality of medical care. The length of stay and the amount of medical care supplied during being in hospital dropped significantly for both single-eye and double-eyes cataract surgery groups. The amount of antibiotic use went down during the hospitalization and upon discharge from the hospital, but decreased after dischrge. The total medical bills and the rate of basic examination implementation increased in the OPD before hospitalization but after discharge dropped. For double-eyes cataract patients, the rate of double-eyes cataract surgery went down. The total medical bills of DRG payment system converted into the fee-for-service system was greater by 113.3% for the single-eye cataract surgery group and by 102.9% for the doble-eyes cataract surgery group, compared to that by the fee-for-service. The contribution shared by the insurance corporation increased for both single-eye and double-eyes cataract surgery groups, but the copayment by the insured went down. Regarding the treatment outcome, no difference was found in complication rate, resurgery rate and mortality rate before and after the joining to the DRG payment system was implemented. The use of special lens lessened significantly. The amount of medical care supplied during hospitalization decreased but the complication rate didn`t increase. But the increased use of low-price artificial cataract and the avoidance of double-eyes cataract surgery was observed. The phenomenon decreased number of OPD visit and the decreased total medical bills of OPD care after discharge in this hospital required further evaluation.

의료보험 고도의료이용자 보호방안에 관한 연구

김윤미 최신의학사 1993 最新醫學 Vol.36 No.11

The Relationship between Depressive Symptoms in Outpatients with Chronic Illness and Health Care Costs

Na, Yu-Mi,Kim, Kwang-Soo,Lee, Kyoung-Uk,Chae, Jeong-Ho,Kim, Jin-Ho,Kim, Dai-Jin,Bahk, Won-Myong,Jang, Yun-Sig,Lee, Ae-Kyoung,Woo, Young Sup,Lee, Pyeoung-Soo Yonsei University, College of Medicine 2007 Yonsei medical journal Vol.48 No.5

<P><B>Purpose</B></P><P>To evaluate the relationship between depressive symptoms and health care costs in outpatients with chronic medical illnesses in Korea, we screened for depressive symptoms in 1,118 patients with a chronic medical illness and compared the severity of somatic symptoms and health care costs.</P><P><B>Patients and Methods</B></P><P>Data were compared between outpatients with depressive symptoms and those without depressive symptoms. Depression and somatic symptoms were measured by Zung's Self-rating Depression Scale (SDS) and Patient Health Questionnaire (PHQ)-15, respectively. We also investigated additional data related to patients' health care costs (number of visited clinical departments, number of visits made per patients, and health care costs). A total of 468 patients (41.9%) met the criteria for depressive disorder.</P><P><B>Results</B></P><P>A high rate of severe depressive symptoms was found in elderly, female and less-educated patients. A positive association between the severity of somatic symptoms and depressive symptoms was also identified. The effects of depressive symptoms in patients with chronic illnesses on three measures of health services were assessed by controlling for the effects of demographic variables and the severity of somatic symptoms. We found that the effects of depressive symptoms on the number of visited departments and number of visits made per patients were mediated by the severity of somatic symptoms. However, for health care costs, depressive symptoms had a significant main effect. Furthermore, the effect of gender on health care costs is moderated by the degree of a patient's depressive symptoms.</P><P><B>Conclusion</B></P><P>In summary, there is clearly a need for increased recognition and treatment of depressive symptoms in outpatients with chronic medical illnesses.</P>

Prehabilitation for medically frail patients undergoing surgery for epithelial ovarian cancer: a cost- effectiveness analysis

Jhalak Dholakia,David E. Cohn,Michael Straughn, Jr,Sarah E. Dilley 대한부인종양학회 2021 Journal of Gynecologic Oncology Vol.32 No.6

Objective: To assess the potential cost-effectiveness of prehabilitation in medically frail patients undergoing surgery for epithelial ovarian cancer (EOC). Methods: We created a cost-effectiveness model evaluating the impact of prehabilitation on a cohort of medically frail women undergoing primary surgical intervention for EOC. Cost was assessed from the healthcare system perspective via (1) inpatient charges from 2018–2019 institutional Diagnostic Related Grouping data for surgeries with and without major complications; (2) nursing facility costs from published market surveys. Major complication and non-home discharge rates were estimated from the literature. Based on published pilot studies, prehabilitation was determined to decrease these rates. Incremental cost-effectiveness ratio for cost per life year saved utilized a willingness-to-pay threshold of $100,000/life year. Modeling was performed with TreeAge software. Results: In a cohort of 4,415 women, prehabilitation would cost $371.1 Million (M)versus $404.9 M for usual care, a cost saving of $33.8 M/year. Cost of care per patient with prehabilitation was $84,053; usual care was $91,713. When analyzed for cost-effectiveness, usual care was dominated by prehabilitation, indicating prehabilitation was associated with both increased effectiveness and decreased cost compared with usual care. Sensitivity analysis showed prehabilitation was more cost effective up to a cost of intervention of $9,418/patient. Conclusion: Prehabilitation appears to be a cost-saving method to decrease healthcare system costs via two improved outcomes: lower complication rates and decreased care facility requirements. It represents a novel strategy to optimize healthcare efficiency. Prospective studies should be performed to better characterize these interventions in medically frail patients with EOC.

요양병원과 병원에 입원한 노인의 의료비용의 현황과 문제점

정혜영,이지전,이상욱 關東大學校 醫科大學 醫科學硏究所 2003 關東醫大學術誌 Vol.7 No.2

In this study, the problem and current condition of healthcare cost among elderly inpatients in general hospitals and long-term care hospitals were investigated. The cost and the items of healthcare among 577 elderly inpatients that were hospitalized in 3 long-term care hospitals and 2 general hospitals was examined by detailed bills for health insurance corporation and patients. Average length of stay was 118 days. Average healthcare cost per a day was 72,312 Won.57% of the benefit cost was covered by healthcare insurance and 43% was out of the pocket money. Among the health insurance beneficiaries, coverage rate was below 50%. The amount of 52% of out of the pocket money was spent on nursing care fee provided by unskilled caregivers. Among medical care beneficiaries excluding psychiatric patients, the ratio of medical care benefit cost out of the pocket money was about 32% of medical care benefit cost, and among psychiatric patients in medical care beneficiaries, out of the pocket money reached 71% of benefit cost.

의료서비스 선택과 비급여 의료비 부담: 일본 혼합진료금지제도 고찰

오은환 ( Eun-hwan Oh ) 한국보건행정학회 2021 보건행정학회지 Vol.31 No.1

With the introduction of national health insurance, the burden of health care costs decreased and choices of medical services widened. However, because of the rapid expansion of non-covered medical services by health insurance, financial security for health care expenditure is still low. This gives patients barriers to choose medical services especially for non-covered medical services, and it becomes narrower. Compared to Korea, Japan has high financial protection in health care utilization, but there exists a limitation using covered and non-covered medical services both together. This is called a prohibition of mixed treatment in health care. This study reviews the Japanese health care system that limits choosing medical services and the burden of health care costs. The prohibition of mixed treatment can alleviate the out-of-pocket burden in the non-benefit sector, but it can be found that it has a huge limitation in that it places restrictions on choices for both healthcare professionals and patients.