소득계층별 의료접근성 분석과 국민건강보험 보장률의 재해석

김대환 ( Daehwan Kim ) 한국보험학회 2018 保險學會誌 Vol.114 No.-

우리나라 보건의료체계에서 발생하는 문제들의 주요 원인이 비급여의료에 있다는 지적은 많은 선행연구에서 제시되었다. 급여의료와 달리 비급여의료는 진료행위 및 진료비 적정성을 정부가 관여하기 않기 때문에 비급여의료에 대한 신뢰할 수 있는 정보가 부재하며, 나아가 의료기관을 대상으로 한 설문조사에 근거하여 정부가 산출해 온 국민건강보험의 보장률도 신뢰성 문제가 제기되어 왔다. 이에 본 연구에서는 한국의료패널의 2011~2015년 자료를 활용해 의료공급자가 아닌 환자가 지출한 의료비 정보에 근거하여 소득계층별 보장률을 산출하였다. 분석 결과, 본 연구에서 산출한 국민건강보험의 보장률이 정부가 발표해 온 수치에 비해 낮은 것으로 나타났다. 무엇보다 소득계층별 그리고 직군(직장 또는 지역가입자)별 보장률은 정부의 수치와는 매우 상이하기 때문에 신뢰할 수 있는 보장률 지표를 산출하기 위한 노력이 필요하겠다. 본 연구에서는 국민건강보험의 보장률 산출과 함께 소득계층별로 보장률 차이가 발생하는 원인을 규정하고자 하였다. 소득수준이 낮을수록 국민건강보험의 보장률은 높은데, 회귀분석 결과 소득수준이 낮을 경우 비급여의료에 대한 접근성이 취약하기 때문에 보장률 산식에서 분모의 크기가 작아서 보장률이 높아질 수 있는 것으로 확인되었다. 그러므로 소득수준이 낮을수록 보장률이 높은 것은 국민건강보험이 사회보험으로써 갖는 순기능이 아닌 비급여의료의 문제로 파급되는 부작용이라 평가될 수 있겠다. 또한 비급여의료에 있어서 소득계층별 형평성 문제가 야기되고 있음을 의미한다. 비급여의료가 순수한 선택의료라면 소득계층별 접근성 문제를 심각한 사회문제로까지 확대해석할 필요는 없겠으나 우리나라의 경우 치료에 필수적인 의료까지 비급여의료의 영역에 방치되어 있기 때문에 정부가 비급여의료도 급여화하여 모든 진료행위와 진료비의 적정성을 심사하는 것이 바람직하다. Prior studies have indicated that the non-covered medical service under national health insurance is the main cause of various problems in health care system. Since unlike the covered medical service, the decision of offering non-covered medical service and its price is delegated to medical suppliers, there is no credible information regarding the non-covered medical service and it can hardly be doubted that the coverage rate calculated by the government is incredible as well. Utilizing most recent data from 2011 to 2015 of the Korean Health Panel, this study calculate the coverage rate by income level based on the information obtained from not the medical suppliers but the patients. It is presented that the coverage rates in this study is lower than that published by the government and there is no a hugh difference two coverage rates. The gap between two coverage rates is, however, significant when it comes to income level and occupational group. In addition to calculating the coverage rate, this study aims to make a close inquiry into the disparate coverage rate among people in different income groups. Regression results show that the high coverage rate for the low income people boils down to their vulnerable access to non-covered medical service of them. That is because the coverage rate increases as the consumption amount of the non-covered medical service which is a component part of the denominator of the formula for the coverage rate decreases. That is, the high coverage rate for the low income people is not the pros but cons of the national health insurance in Korea, which is resulted from the non-covered medical service. This further erodes the principle of equity, which is one of the main roles of the public insurance. If the non-covered medical service contains only non-essential services, losing fairness is not necessarily considered as a serious social problem. Essential medical services are, however, dealt as non-covered medical service. Thus, the government must deal with the non-covered medical service as the covered medical service and monitor the decision of any offering medical service and its price.

종합병원에서 진료량과 의료이익의 관계

임민경 ( Min Kyoung Lim ),김정하 ( Jeongha Kim ),김선제 ( Sunjea Kim ) 한국병원경영학회 2021 병원경영학회지 Vol.26 No.3

Purpose: We examined the relationship between operating income and volume of medical services provided at general hospitals in 2018 according to characteristics of general hospitals and measured as operating income(net income) and volume(adjusted inpatient days) covered or non-covered by National Health Insurance(NHI). Methodology: Finance data from income statement reports in 212 general hospitals and the national health insurance claim data of these hospitals were used. The characteristics of the general hospital were divided into structural, operational, financial, and patient aspects. Operating income and volume were divided into covered and non-covered by NHI. Findings: The results showed high volume hospitals tended to be more profitable than low volume hospitals, especially in non-covered services. Operating income was more likely to be sensitive to non-covered services volume than to covered services volume. Practical Implications: It is necessary to understand the volume of services in non-covered, in order to obtain reliable cost information to be used for the fee schedule. Researches on small size hospitals(<160 beds) are needed, with a large variation in the volume of services and a strong tendency to compensate for the loss in the covered part in non-covered part.

병원의 설립형태 및 수익성과 비급여 서비스 가격의 연관성

김도희,김태현 한국병원경영학회 2023 병원경영학회지 Vol.28 No.1

Purposes: There exist many non-covered services that the National Health Insurance does not cover, and thus, their prices are set by individual health care providers. However, little study has been done to investigate how hospitals set prices for those services. The purpose of this study is to examine the relationship between ownership, profitability, and prices of those services for a sample of general hospitals. Methodology/Approach: Data regarding the prices of major non-covered services (e.g., upper-level hospital room fees, MRI, Da Vinci robot surgery, and LASIK) were obtained from the Health Insurance Review and Assessment Service and the financial information, as well as other characteristics, were derived from the financial reports from the Korea Health Industry Development Institute. Descriptive statistics, t-tests, and multiple linear regression analyses were used to test the relationship between the independent variables and the dependent variables. Findings: Hospitals owned by private universities appeared to have higher prices for non-covered services while regional public hospitals tend to have lower prices. Profitability, measured by operating margin, was not significantly related to the prices. Hospitals that charge higher prices were more likely to be located in the capital area (Seoul, Incheon, and Gyeonggi), and to employ larger number of personnel. Practical Implications: Public hospitals tend to charge lower prices for non-covered services. Relative market power appears to be related to pricing. Further research is needed to investigate whether such a relationship varies over time and its effects on the quality and access.

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.

노인장기요양보험 시설서비스 이용자의 비급여 본인부담 크기 및 영향요인

권진희,이정석,한은정 한국보건행정학회 2012 보건행정학회지 Vol.22 No.1

The purpose of this study is to understand magnitude and its related factors of user's cost-sharing for non-covered services in long-term care facilities. We corrected data for 1,016 subjects, based on the long-term care benefits cost specification. Eighteen subjects were excluded from the data analysis due to missing data on family care-givers characteristics. Finally, 998 subjects were included in the study. The average cost of non-covered services per month was 209,093 won and distributed from 0 to 1,011,490 won. There was a significant difference by the characteristics of family care-givers and long-term care facilities. The monthly average cost for meal materials per person was 199,181 won(0~558,000), average cost of additional charge caused by using private bed was 232,992 won (50,000~600,000), and costs for haircut and cosmetics were 8,599 won. For the rest, there were various programs costs(93,328 won), diaper and its disposal cost(109,628 won), purchase cost for daily necessaries(24,435 won) and etc. The related factors for the magnitude of non-covered services expenditures were education level of family care-givers, occupancy rate and location of LTC facilities, and the costs of using private bed, haircut and cosmetics, and various programs among non-covered services. These findings suggest that present level range of LTC facilities users' cost-sharing is wide and it is urgent to prepare the standard guideline for cost and level in non-covered services.

선택진료 및 상급병실제도 개선정책이 건강보험 보장성에 미친 영향: 일개 상급종합병원 입원 진료비를 중심으로

나비 ( Bee Na ),은상준 ( Sang Jun Eun ) 한국병원경영학회 2018 병원경영학회지 Vol.23 No.1

Purposes : In February 2014, the government said that the National Health Insurance Service (NHIS) will enforce plan for reducing the financial burden from two major non-covered services including physician surcharges and private room charges, the main causes to increase uninsured, by 2017. The purpose of this study is to analyze the policy effect that performed so far by comparing out-of-pocket payment rates of policy process Methodology: This study analyzed admission medical expenses that occurred from January 2013 to March 2016 at a upper grade general hospitals in Daejeon. Number of study subjects were 134,924 and the data were analyzed with SPSS 22.0 program by using frequency, percentage, mean, standard deviation, ANOVA. The effect of two major non-payment improvement plan on out-of-pocket rates was ascertained via generalized estimating equation. Findings: Out-of-pocket payment rates was statistically significantly declined 2.7 percent than enforcement ago. Also, out-of-pocket payment, physician surcharge, the proportion of out-of-pocket payment of hospital room charge to out-of-pocket payment was statistically significantly declined. However, a further analysis of the cause of the decline in total medical costs is needed. Practical Implications: Physician surcharges and private room charges improvement policy had a positive effect on the decline of out-of-pocket payment rate. The policy of physician surcharges was very effective after the first policy enforcement but it was less effective to medical aids and near poor that was a more greater coverage than national health insurance. Since the policy has not been finalized, we have to continue a research for the successful implementation of the policy.

문재인 정부의 건강보험 보장성 강화대책

박은철,Park, Eun-Cheol 한국보건행정학회 2017 보건행정학회지 Vol.27 No.3

Moon Jae-in Government announced the Government's 5-Year Plan on July 19, 2017, President Moon directly announced the Government's Plan for Benefit Expansion in National Health Insurance on August 7, 2017. The main contents of the announced expansion include benefit coverage for all medically necessary services with control over non-covered service occurrence, a decrease in the cost-sharing upper limit, and monetary support for catastrophic medical costs. Although past governments have been continuously striving for benefit expansion in the last 15 years, this plan has its breakthrough aspect in that all medical services will be covered by the National Health Insurance. In alignment, there are important tasks to solve: attaining a proper fee schedule, reforming the healthcare delivery system, and improving healthcare quality. This plan is a symptom oriented action in that it is limited in reducing patients' out-of-pocket money, unlike the systematic approach of the National Health Insurance. The sustainability of the National Health Insurance is being threatened due to South Korea's low birth rate, rapidly aging society, and low economic growth, in addition to the unification issue of the Korean Peninsula, medical utilization of the elderly, management of non-communicable diseases, and so on. Therefore, the Government needs to plan the National Health Insurance system reformation including actions addressed toward medical consumers.

4대 중증질환 보장성 정책이 환자의 의료이용과 재난적 의료비에 미친 영향 - 성향점수매칭과 이중차이분석을 활용하여 -

이현옥 한국사회복지학회 2018 한국사회복지학 Vol.70 No.1

The purpose of this study is to analyze the causal effects of the four major severe diseases benefit expansion policy implemented in 2013 on the health care utilization and catastrophic health expenditure of treatment groups. As a result of the simple difference-in-difference model, the four major severe diseases benefit expansion policy was effective in reducing the out-of-pocket payments and Non-covered services expenditures of the treatment group. However, no statistical significance was found in the number of outpatient visits and inpatient and the incidence of catastrophic health expenditure of the four major severe diseases household. The implications of this study are as follows. First, the effect of the four severe disease benefit expansion policy was identified through the non-covered medical services, an area in which previous research was insufficient. Second, in the analysis process, it was confirmed that the control group, patients with chronic illness or the non-four severe diseases, were experiencing similar medical expenses and catastrophic health expenditure like a severe diseases. Therefore, it is necessary to extend the benefit expansion policy not only to the four severe diseases but also to other diseases. This suggests that “Moon Jae-in care”, which is currently being implemented by the government, should be implemented immediately for all patients beyond the four major severe diseases. 본 연구의 목적은 2013년 시행된 4대 중증질환 보장성 강화 정책이 수혜대상의 의료이용과 대상가구 의 재난적 의료비에 미친 인과적 효과를 분석하는 것이다.분석 자료는 한국의료패널 2012년과 2014년 자료를 활용하였고,전체 3400명의 개인과 1700 가구를 분석대상으로 하였다.이중차이분석 결과, 4대 중증질환 보장성 강화 정책은 수혜대상의 본인부담금과 비급여 진료비를 경감하는데 통계적으로 유의미한 효과가 나타난 반면,의료이용횟수와 중증질환 가구의 재난적 의료비의 발생여부에는 유의미한 효과가 나타나지 않았다.보장성 정책의 인과적 효과는 4대 중증질환 환자의 의료비는 다소 경감시켰으나 지불능력 대비 과다한 의료비 지출로 인한 가구의 재정적 어려움을 해소하기에는 부족하였다. 논문의 함의는 4대 중증질환 보장성 강화 정책의 효과를 비급여 진료비를 통해 파악하였다. 또한 건강보험에서 규제되지 않는 비급여 진료비에 대한 전면적 급여 확대의 필요성을 확인하였다. 분석과정에서 대조군인 만성질환 및 비4대 중증질환자 역시 과중한 의료비 부담과 높은 재난적 의료비 발생률을 경험하는 것을 확인하였다. 이는 4대 중증질환에 한정된 보장성 정책을 넘어 현재 정부에서 추진중인 문재인 케어가 조속히 시행되어야 함을 시사한다.

정부 건강보험 보장성 확대방안의 쟁점과 과제

김계현 ( Kim Kye-hyun ),김한나 ( Kim Han-nah ) 제주대학교 법과정책연구원 2018 法과 政策 Vol.24 No.2

President Moon directly announced the Government’s Plan for Benefit Expansion in National Health Insurance on August 7, 2017. The main contents of the announced expansion include benefit coverage for all medically necessary services with control over non-covered service occurrence, a decrease in the cost-sharing upper limit, and monetary support for catastrophic medical costs. Although past governments have been continuously striving for benefit expansion in the last 15 years, this plan has its breakthrough aspect in that all medical services will be covered by the National Health Insurance. The government recently announced strengthening the plan for health insurance coverage. the purpose of this plan was to increase the coverage rate by up to 70%. The government has suggested detailed plans but there remain many controversial issues and limitations with regard to the practical aspects. Thus, further research and suggestions are needed. This paper analyzed the main contents and problems of the government’s plan for benefit expansion in national health insurance system, and considered tasks and improvement in the future. The results of the study are as follows: In health care, the benefit coverage rate is an important issue. However, in order to increase the coverage within a limited reset, the mandatory items should be identified first. Principles and methodologies to set priorities need to be discussed and agreed with experts. In addition, the scope extension plan should also take into account the improvement of the medical delivery system and restrictions on medical use, reflecting the characteristics of Korean medical use. Finally, the improvement of the health insurance system requires a long-term financial management plan and a comprehensive plan.

외생적 가격구조하에서 의료공급자 경쟁이 진료량에 미치는 영향

유혜림,민인식 한국보건사회연구원 2022 保健社會硏究 Vol.42 No.2

The analysis of competition among healthcare providers is important in measuring the effects of competition mechanisms at the market level and national medical expenses and medical resource distribution at the national level. This study aims to provide both theoretical and empirical evidence of the effect of healthcare provider competition under the fixed price. This study investigates a theoretical model of healthcare provider competition using the circular city model (Salop, 1979). A proposition derived as a result is, the intensity of care increases with the number of providers. Empirical work examines the theoretical results of the theoretical framework. The impact of provider competition on the intensity of care is investigated by a panel random effect model using NHIS (National Health Insurance Service)-cohort 2.0 DB data based on National Health Insurance claims data. The estimated results show that the proposition is supported empirically as the intensity of care increased with the number of providers. 의료기관 경쟁에 대한 분석은 시장 기전의 효과를 측정하며 국민의료비와 의료자원분포에 미치는 영향을 파악한다는 측면에서 중요하다. 본 연구는 국내 의료시장에서 급여서비스를 중심으로 외생적 가격구조하에서의 의료공급자 경쟁의 영향을 경제학적 이론분석과 실증분석에 기반하여 다각도로 분석하는 것을 목적으로 한다. 미시이론모형인 Salop(1979)의 원형도시모형(circular city model)으로 분석한 결과, 경쟁이 증가함에 따라 최적 진료강도는 증가하며, 의료공급자 수가 충분히 커질수록 추가적인 경쟁이 진료강도에 미치는 영향은 작아진다는 명제를 도출하였다. 명제가 실증적으로 지지되는지 분석하기 위하여 국민건강보험공단의 표본코호트 DB 2.0를 이용해 패널 확률효과모형(panel random effect)을 추정하였다. 분석 결과, 의료공급자 경쟁이 증가할수록 진료강도가 증가하여 도출된 명제가 실증적으로 지지됨을 보였다. 본 연구 결과를 토대로 해석하면 우리나라의 의료기관 경쟁은 경쟁으로 인한 가격하락을 예측하는 고전적 경제학의 예측 결과보다는 의료군비경쟁가설을 지지하는 것을 알 수 있다. 의료기관 경쟁이 진료강도와 가격을 상승시키는 의료군비경쟁으로 나타나지 않도록 경쟁을 고려한 의료자원 분배가 필요하며, 진료강도와 가격을 관리하기 위하여 기관단위 청구현황을 모니터링 고도화, 행위별 수가 외의 대안적 지불제도 검토가 필요할 것이다.