자문형호스피스 시범사업 성과평가 및 건강보험 적용방안 연구

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HospiceHospice servicesPalliative carePalliative services
Background: On August 14, 2017, the Ministry of Health and Welfare (MOHW) of South Korea implemented the "Consultative Hospice Care (COHC)" for terminally ill patients in the acute-care wards. COHC is different from the hospice care provided in the Independent Hospice Unit (IHU) in that COHC was offered to those in acute-care wards. There has been no study that evaluated this pilot project.

Objective: To evaluate the COHC project and to review application potential and method of the national health insurance system (NHIS).

Results: There were 27 hospitals participating in the project as of December 31, 2019. A total of 7,910 patients received COHC for 2.5 years. This study evaluated the project in the standpoints of structure, process, and results. As for structure, although accessibility to COHC varied upon regions, the level of
appropriateness on staffing, governance, training system, and fee schedule showed above the average. Regarding process, average length of stay of COHC patients was 19.1 days which did not differ by type of hospitals nor type of insurance status (NHIS or Medical Aid). Waiting time for COHC was shorter than those of IHU. Denial rate of registrating COHC after initial consultation was 47.8%. Although the delivery of COHC was well processed, some communication difficulties were observed between attending physicians of acute-care unit and those in COHC program. Percent of non-cancer patients was as low as 1.5%. Among COHC and IHU patients who used hospice care for the first time during their entire life, COHC inpatients took up 21.3% of all patients. For result perspective, total healthcare expenditure (HE) and daily health expenditure of COHC per patient were approximately KRW 9 million and KRW 450,000 respectively. Inpatient HE of COHC per patient before 6-month death was higher than those of IHU, but lower than that of cancer patients. Both total and daily expenditure of COHC per patient were much lower than IHU and cancer patients. The COHC program was effective on early entry of terminally ill patients to a hospice program. Patient pain level significantly decreased after 7th day from admission to COHC. However, satisfaction level was relatively low among patient’s family and
general public using COHC program compared to that of IHU. There are a set of prerequisite to cover COHC under NHIS efficiently. First, the government should increase the number of COHC providers to reduce accessibility imbalance by region. Second, current healthcare delivery system needs to improve connectivity to palliative medical care and hospice care including COHC. Third, the government should introduce evaluation program to COHC and provide financial incentives to high-performing hospice
providers upon the result. The quality assessment should reflect experience of patients and their family as the main input, and additional evaluation item should include the structure, process, and outcome of hospice service. Fourth, the government should add a few new items to the fee schedule and/or
adjust existing fees. To name a few, pre-consultative service fee can be newly introduced, and rate on the use of bereavement room in hospitals should be increased. Last but not least, other necessary items include standardization of COHC practice guideline, sharing and utilization of hospice data for quality improvement, and development of governance for policy support.

Discussion: Although the HE of COHC was higher than those of IHU, overall performance level of COHC project was successful in structure, process, and outcome. Observed issues were predicted given the integration of palliative care and hospice care, and delivery of hospice services in acute-care setting. Thus, the government needs to prepare policies to allow hospice and palliative care to develop independently, yet in a mutually beneficial way, so that the quality of care can improve significantly in both hospice and palliative care.
Alternative Title
A Study on the Evaluation of the National Hospice Pilot Project providing Consultative Hospice Services in General Wards and the Application Plan for the National Health Insurance Program
Table Of Contents
제1장 서 론 -------------------------- 1
1. 연구 배경 -------------------------- 1
2. 연구 목적 -------------------------- 2
3. 연구내용 및 방법 -------------------------- 3
가. 연구내용 및 수행체계 -------------------------- 3
나. 연구방법 -------------------------- 4
다. 데이터 전처리 방법 -------------------------- 8

제2장 성과평가체계 및 평가지표 선정 -------------------------- 13
1. 호스피스의 정의 -------------------------- 13
2. 호스피스 관련 국내 선행연구 -------------------------- 14
3. 성과지표 평가의 구조적 틀 -------------------------- 15
4. 외국의 성과평가 지표 -------------------------- 16
5. 자문형호스피스 시범사업 성과평가 대분류 지표선정 -------------------------- 18
6. 성과평가 목표와 체계 -------------------------- 19
가. 시범사업 목표 -------------------------- 19
나. 정책목표와 측정지표 -------------------------- 20
다. 성과 및 정책목표 평가 선정지표 -------------------------- 22

제3장 자문형호스피스 시범사업 성과평가 -------------------------- 25
1. 구조 평가 -------------------------- 25
가. 시설: 시설분포 및 접근성 -------------------------- 25
나. 인력 - 적정성 -------------------------- 29
다. 관리체계 -------------------------- 33
라. 교육 -------------------------- 38
마. 수가 -------------------------- 39
2. 과정 평가 -------------------------- 42
가. 의료이용 -------------------------- 42
나. 서비스 제공내용 및 체계: 돌봄상담, 임종관리, 임종실료 등 -------------------------- 50
다. 질병유형 -------------------------- 58
라. 연계 -------------------------- 61
3. 결과 평가 -------------------------- 67
가. 비용 -------------------------- 67
나. 조기개입 -------------------------- 77
다. 임종의 질 -------------------------- 79
4. 자문형호스피스 시범사업에 대한 의료기관 전문가 평가 -------------------------- 88
5. 자문형호스피스 시범사업 평가요약 및 소결 -------------------------- 89

제4장 대만의 호스피스·완화의료 현황 -------------------------- 95
1. 대만 호스피스·완화의료 제도 개요 -------------------------- 95
2. 자문형호스피스 도입 및 확대 -------------------------- 96
3. 서비스 유형 및 수가 -------------------------- 97
가. 서비스 유형 -------------------------- 97
나. 수가 -------------------------- 99
4. 서비스 제공 및 이용 -------------------------- 100
5. 자문형호스피스·완화의료 평가 -------------------------- 102
가. 의료이용 및 사업성과 -------------------------- 102
나. 비용 절감 -------------------------- 105
6. 소결 -------------------------- 107

제5장 자문형호스피스 건강보험 적용방안 ------------------------- 109
1. 호스피스와 완화의료의 향후 정책방향 ------------------------- 109
2. 자문형호스피스 제공모형 ------------------------- 112
가. 모형의 정의 ------------------------- 112
나. 자문형호스피스 서비스제공 과정 ------------------------- 113
다. 국내의 호스피스 모형연구 사례 ------------------------- 114
라. 건강보험 적용 모형 ------------------------- 116
3. 자문형호스피스 건강보험 적용방안 ------------------------- 117
가. 전국적 시설규모 ------------------------- 117
나. 인력규모 ------------------------- 120
다. 연계체계 ------------------------- 120
라. 관리체계 ------------------------- 126
마. 수가 ------------------------- 127
바. 교육 ------------------------- 129
4. 자문형호스피스 서비스 제공수준 및 질 관리 방안 ------------------------- 130
가. 서비스 제공수준 ------------------------- 130
나. 질 관리 및 평가 방안 ------------------------- 132
5. 자문형호스피스 본 사업 도입 시 고시개정 및 연간소요재정 ------------------------- 135
가. 본 사업 도입시 고시개정 방안 ------------------------- 135
나. 연간 소요 재정 ------------------------- 136

제6장 결론 및 정책제언 ------------------------- 143
1. 연구결과 요약 ------------------------- 143
가. 자문형호스피스 시범사업 평가 ------------------------- 143
나. 대만의 사례가 주는 시사점 ------------------------- 145
다. 건강보험 적용방안 ------------------------- 146
2. 정책제언 ------------------------- 148

참고문헌 ------------------------- 155

국문초록 ------------------------- 159

ABSTRACT ------------------------- 161

부 록 ------------------------- 163
박영택 et al. (202011). 자문형호스피스 시범사업 성과평가 및 건강보험 적용방안 연구.
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