신포괄수가에 영향을 미치는 의료행태 요인 분석 - 내과 입원환자 중심으로 = The analysis of medical care behaviors influencing New Diagnosis-Related Groups (DRG) based payment - focused on hospitalized patients with medical illness

다국어 초록 (Multilingual Abstract)

Purpose: The purpose of this study is to investigate medical care behaviors influencing accuracy of the payment based New diagnosis-related groups (DRG) compared to fee for service (FFS) in hospitalized patients with medical illness.
Methodology: In order to estimate the difference in medical costs between New DRG and FFS depending on medical care behaviors, medical records and hospital claims data (n=4,232) were utilized, which were collected from a single public hospital during the first-half of 2018. Data were analyzed by descriptive statistics, t-test, chi-square test, and multivariate binary logistic regression.
Findings: The average difference in medical costs between New DRG and FFS were KRW 506,711±13,945 with incentives and KRW -51,506±12,979 without incentives, respectively. Forty-four point two percent (44.2%, n=1,872) of total subjects were shown to have negative compensation in overall medical costs with New DRG compared to the costs with FFS. Medical care behaviors that affected on the negative compensation were the presence of severe bed sores on admission, medical consultations, death, operations, medications and laboratory or imaging tests with unit price over KRW 100,000, hospital-acquired complications or underlying comorbidities, elderly patients (≧65 years), and hospitalized for more than average inpatient days defined by New DRG (p<0.001). The difference in average medical cost between New DRG and FFS for a group with mild illness was KRW –11,900±10,544, whereas it was KRW –196,800±46,364 for a group with severe illness (p<0.0001).
Practical Implications: These findings suggest that New DRG payment model without incentives may incompletely cover the variation of medical costs in real clinical practice. Therefore, policy makers need to consider that the current New DRG reimbursement should be focused and refined to improve accuracy of payment on medical care resources utilized in severe and complex medical conditions.

참고문헌 (Reference)

1 송혜숙, "포괄수가제(DRG) 대상자의 인식과 태도 및 만족도에 관한 연구" 사단법인 대한보건협회 39 (39): 37-45, 2013

2 최재욱, "포괄수가제 시행으로 인한 의료비 감소와 의료의 질" 대한의사협회 55 (55): 706-709, 2012

3 김남리, "지방의료원 의사들의 신포괄수가제도에 대한 인식" 한양대학교 공공정책대학원 2013

4 신동교, "중증도 분류에 따른 진료비 차이: 간질환을 중심으로" 한국보건행정학회 23 (23): 35-43, 2013

5 Song GY., "의료시장 개방에 대비한 민간병원의 경쟁력 강화방안 연구" 2004

6 건강보험심사평가원, "신포괄지불제도 시범사업지침"

7 강길원, "신포괄수가 조정기전개발 연구" 건강보험심사평가원 2014

8 강길원, "[주제토론 1] 우리나라 진료비지불보상제도의개혁: 신포괄수가제 도입의 의의와 주요 논쟁점" (2) : 21-37, 2010

9 Burns LR, "The effects of patient, hospital, and physician characteristics on length of stay and mortality" 29 (29): 251-, 1991

10 Humbyrd CJ, "The Ethics of Bundled Payments in Total Joint Replacement : "Cherry Picking"and"Lemon Dropping"" 28 (28): 62-, 2018

11 Shin ES, "The Effect of New Diagnosis Related Group based Payment on the Length of Stay" The Catholic university 2017

12 Yun HJ, "Study on the Meadical Services Granted in Accordance with The Applicable Reduction of The DRG Payment System" Konkuk university 2016

13 Hwang SH, "Quality of care for public and private hospitals in Korea" 1 (1): 145-156, 2017

14 Rogers WH, "Quality of care before and after implementation of the DRG-based prospective payment system. A summary of effects" 264 (264): 1989-, 1990

15 Rogers WH, "Quality of care before and after implementation of the DRG-based prospective payment system. A summary of effects" 264 (264): 1989-1994, 1990

16 R Koivuniemi, "Infectious Causes of Death in Patients With Rheumatoid Arthritis: An Autopsy Study" 35 (35): 273-276, 2006

17 Louis, D. Z, "Impact of a DRG-based hospital financing system on quality and outcomes of care in Italy" 34 (34): 405-415, 1999

18 Carter GM, "How much change in the case mix index is DRG creep?" 9 (9): 411-, 1990

19 Dismuke C.E, "Has DRG Payment Influenced The Technical Efficiency and Productivity Of Diagnostic Technologies In Portuguese Public Hospitals? An Empirical Analysis Using Parametric And Non-Parametric Methods" 2 (2): 107-116, 1999

20 Son CW, "Effects of New Diagnosis Related Group based Payment on Service Provision and Quality of Care" Seoul National university 2015

21 Kim GD, "Effects of New Diagnosis Related Group based Payment on Efficiency of Hospitals" Seoul National university 2017

22 Kim YY, "Effect of the Korean Case Payment System on the Length of Stay and Readmission" Seoul National university 2015

23 Busse R, "Diagnosis related groups in Europe: moving towards transparency, efficiency, and quality in hospitals?" 346 : f3197-, 2013

24 Kusserow RP, "DRG "creep". Pitfalls and sanctions to avoid" 29 (29): 93-99, 1989

25 Ospel JM, "Cherry-picking the Wrong Patients has to be Avoided at all Cost!" 30 (30): 43-, 2020

26 Fitzgerald JF, "Changing patterns of hip fracture care before and after implementation of the prospective payment system" 258 (258): 218-, 1987

27 Siess M, "Auswirkungen des DRG basierten Entgeltsystems. Welcher Handlungsbedarf besteht für den Chirurgen? [Effects of the DRG-based payment system. What action requirement exists for the surgeon?]" 72 (72): 30-, 2001

28 Paul M, "A research paradigm for severity of illness:Issues for the diagnosis-related group system" 79-90, 1984

29 Kim SI, "A Study on Adequacy of Medical Fee in New DRG-based Prospective Payment System" Korean Medical Association 2018