요양급여 적정성평가 중기 발전방안

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HIRAHealth Insurance Review & AssessmentQuality Assessment in Healthcare BenefitsQuality of CarePatient-CenterednessGoal-based AssessmentValue-based AssessmentValue-based Incentive Program
The Quality Assessment in Healthcare Benefit was introduced in July 2000 based on the National Health Insurance Act in order to improve quality of care in balanced manner. Since the system adoption and implementation, some have criticized the lack of national-level goal for healthcare performance area and quality improvement, and inadequate structured approach with respect to the aim of quality. There have been growing demands for assessment system reform to ensure the quality measurement and to highlight the need for value-based payment system. As such, this paper examined the mid-term development plan for quality assessment to move towards quality and patient-centered value-based review and assessment system.
The research consists of 4 methods, which are literature review, quality assessment material analysis, overseas case review, and advisory council. First, SWOT analysis was deployed on domestic reports to identify current status and issues of quality assessment in healthcare benefit. Second, the effect of quality assessment was checked by reviewing quality assessment results and healthcare Big Data. Third, value-based health system theories and value-based incentive program in the US were analyzed. And fourth, experts provided advice on improvement measures for further
development of quality assessment.
The study outcome showed that quality assessment system has achieved significant quantitative as well as qualitative improvements since 2010 thanks to continued quality report and expert opinion collection. However, some areas still need to be reinforced with addition of new measures, and quality goal is required each indicators could serve as benchmark for quality improvement. In the context of value-based assessment, limitations include unclear definition of value and insufficient
amount of meaningful measures for value assessment. Furthermore, a concrete reimbursement model and execution plan need to be in place to switch from goal-based assessment to value-based assessment.
As such, this paper proposed a framework of assessment system revision and suggested potential interventions to further improve quality assessment, along with 4-staged road map and concrete approaches to facilitate complementary development of goal-based assessment and value-based assessment. First state is to define values and organize quality indicators to improve internal performance. Second is to standardize assessment system and value measurement, and build on integrated quality management system for improved transparency and value connection. Third is to widen result utilization and executive value-based assessment for improved performance and value. And fourth is to develop a nationally integrated assessment system based on continued monitoring and performance charge management in order to support goal-based assessment and value-based assessment so they take
firm root and receive continued monitoring.
Alternative Title
Mid-term Development Plan for Quality Assessment in Healthcare Benefit
Table Of Contents
요 약 ⅰ

제1장 서론 ------------------------------- 1
1. 연구의 배경 및 필요성 ------------------------------- 1
2. 연구의 목적 ------------------------------- 3
3. 연구의 내용 및 방법 ------------------------------- 4

제2장 적정성평가의 이해와 패러다임 변화 ------------------------------- 7
1. 적정성평가의 도입 및 발전 ------------------------------- 7
가. 적정성평가의 도입 ------------------------------- 7
나. 적정성평가의 발전 ------------------------------- 8
2. 심사평가체계의 개편과 적정성평가 ------------------------------- 12
가. 심사평가체계 개편 방향 ------------------------------- 12
나. 가치기반 심사평가 모형 설계 방향 ------------------------------- 14
3. 적정성평가에서 가치기반 ------------------------------- 16
가. 가감지급사업 ------------------------------- 16
나. 만성질환관리 인센티브사업 ------------------------------- 21
다. 의료질평가지원금 제도 ------------------------------- 21
4. 소결 ------------------------------- 25

제3장 요양급여 적정성평가 분석 ------------------------------- 27
1. 요양급여 적정성평가 발전을 위한 연구 동향 ------------------------------- 27
가. 심사평가원의 역할 측면에서 적정성평가 ------------------------------- 27
나. 적정성평가 업무 측면에서 발전 ------------------------------- 32
다. 적정성평가 발전을 위한 주요 제안 ------------------------------- 49
2. 적정성평가의 효과 분석 ------------------------------- 51
가. 양적 측면에서 효과 ------------------------------- 51
나. 질적 측면에서 효과 ------------------------------- 57
3. 소결 ------------------------------- 66

제4장 가치기반 보건의료시스템 고찰 ------------------------------- 71
1. 가치기반 보건의료시스템에 대한 이해 ------------------------------- 71
가. 가치기반의 개념 ------------------------------- 71
나. 가치의 측정 방향 ------------------------------- 73
다. 가치기반 보상과 보건의료체계 ------------------------------- 76
2. 가치기반 평가 이행을 위한 미국의 경험 ------------------------------- 78
가. CMS의 가치기반 평가를 위한 질 지표 관리 ------------------------------- 78
나. 메디케어의 병원가치인센티브 프로그램 HVIP ------------------------------- 84
다. 메디케어의 의사인센티브 프로그램 MIPS ------------------------------- 87
3. 소결 ------------------------------- 93

제5장 가치기반 패러다임에 따른 적정성평가 발전방안 ------------------------------- 97
1. 가치기반 적정성평가로 확대를 위한 검토 ------------------------------- 97
가. 적정성평가의 환경 분석 ------------------------------- 97
나. 가치기반 보상에 관한 전문가 의견 ------------------------------- 100
2. 가치기반으로 확대를 위한 적정성평가의 발전방안 ------------------------------- 106
가. 적정성평가의 발전을 위한 평가체계 중재 방향 ------------------------------- 106
나. 요양급여 적정성평가 개선 틀 ------------------------------- 109
다. 적정성평가의 발전방안 ------------------------------- 112
3. 소결 ------------------------------- 120

제6장 결론 및 제언 ------------------------------- 123
1. 연구의 결론 ------------------------------- 123
2. 연구의 제언 ------------------------------- 125

참고문헌 ------------------------------- 127
ABSTRACT ------------------------------- 133
부 록 ------------------------------- 135
임지혜 et al. (202012). 요양급여 적정성평가 중기 발전방안.
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