의료 질 평가 사례 연구 -미국을 중심으로-

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의료 질 평가미국메디케어메디케이드보건의료가치기반보상사업지불제도건강보험심사평가원Healthcare quality assessment systemQuality programCenters for Medicare and Medicaid Services(CMS)Agency for Health Research and Quality(AHRQ)Health Insurance Review & Assessment ServiceHIRA
Background: The health care quality assessment system has contributed to quality improvement of medical care in Korea. The first comprehensive plan of National Health Insurance (2019-2023) shed light upon the matter of national-level assessment system implementation for quality improvement and the need of goal-oriented comprehensive assessment system. As the focus of health care service is shifting from volume to value, it is time to discuss introduction of new systems to support quality improvement
in response to the changing environment of health sector.

Objectives: This study aims to review the health care assessment systems and case examples of the United States and to investigate lessons and implications for Korea.

Methods: We reviewed health policy reports, academic papers, and webpages (Department of Health and Human Services, Centers for Medicare and Medicaid Services [CMS], and Agency for Health esearch and Quality [AHRQ]).

Conclusion: CMS and AHRQ have developed and put to use various programs for quality improvement. The theoretical concepts of the program, value based purchasing, and programs of using new payment system provide a meaningful foundation for health care quality management. In the future, value-based, patient-centered, medical home, and health data collection are essential for constructing a paradigm. Continuous efforts and management are required to achieve results-oriented interconnectivity, feasibility, and efficiency.
Alternative Title
Health care quality assessment in the United States
: a case study
Table Of Contents
요 약 ⅰ
제1장 서론 ------------------------------------ 1

제2장 의료의 질과 미국의 의료 질 전략 ------------------------------------ 5
1. 의료 질의 정의 ------------------------------------ 5
2. 의료 질의 구성요소 ------------------------------------ 6
3. 미국의 의료 질 평가 배경 ------------------------------------ 8
4. 환자보호 및 부담적정보험법(Patient Protection and Affordable Care Act, PPACA) ------------------------------------ 9
5. 국가 질 전략(National Quality Strategies, NQS) ------------------------------------ 10

제3장 Centers for Medicare and Medicaid Services (CMS) ------------------------------------ 13
1. 개요 ------------------------------------ 13
가. 기능 및 역할 ------------------------------------ 14
나. CMS 질 전략(CMS Quality Strategy) ------------------------------------ 14
다. 메디케어 어드밴티지 질 전략(Medicare Advantage Quality Strategy, MA) ------------------------------------ 17
2. CMS의 질 관리 활동 ------------------------------------ 18
3. CMS의 질 관리 사업(Quality Initiatives, QI) ------------------------------------ 20
가. 병원 질 관리 사업(Hospital Quality Initiative, HQI) ------------------------------------ 24
나. 병원 입원환자 질 보고 프로그램(Hospital Inpatient Quality Reporting Program, HIQR) ------------------------------------ 26
다. 병원 외래환자 질 보고 프로그램(Hospital Outpatient Quality Reporting Program, HOQR) ------------------------------------ 27
4. CMS의 질 향상 보상 사업 ------------------------------------ 28
가. 병원 질 향상 보상 사업(Hospital Quality Incentive Demonstration, HQID) ------------------------------------ 28
나. (구)전자의무기록 프로그램(Electronic Health Records, EHR), (신)상호운용성 촉진 프로그램(Promoting Interoperability Program, PIP) ------------------------------------ 28
다. 질 지불 프로그램(Quality Payment Program, QPP) ------------------------------------ 32
라. 의료 향상을 위한 묶음지불제도(Bundled Payments for Care Improvement Advanced, BPCI Advanced) ------------------------------------ 36
5. 가치기반 프로그램(Value Based Program, VBP) ------------------------------------ 37
가. 말기 신장질환 질 인센티브 프로그램(End-Stage Renal Disease Quality Incentive Program, ESRD QIP) ------------------------------------ 39
나. 병원 가치기반 성과지불제도(Hospital Value-Based Purchasing Program, HVBP) ------------------------------------ 41
다. 병원 재입원 감소 프로그램(Hospital Readmission Reduction Program, HRRP) ------------------------------------ 43
라. 가치 보정 프로그램(Value-Based Modifier Program, VBM or Value Modifier, VM) ------------------------------------ 44
마. 병원획득감염 감소 프로그램(Hospital-Acquired Condition(HAC) Reduction Program, HACRP) ------------------------------------ 44
6. 지표관리시스템(Measures Management System, MMS) ------------------------------------ 46
7. CMS의 정보공개 프로그램 및 질 평가 도구 ------------------------------------ 48
가. 병원비교 웹사이트(Hospital Compare) ------------------------------------ 48
나. 의미 있는 측정 프레임워크(Meaningful Measures Framework) ------------------------------------ 49
8. CMS의 협력체계 ------------------------------------ 53
가. 질향상 조직(Quality Improvement Organizations, QIOs) ------------------------------------ 53
나. 병원 질 연합회 (Hospital Quality Alliance, HQA) ------------------------------------ 54

제4장 Agency for Health Research and Quality (AHRQ) ------------------------------------ 57
1. 개요 ------------------------------------ 57
2. AHRQ의 질 지표 (AHRQuality Indicators) ------------------------------------ 59
가. 질 지표의 관리 ------------------------------------ 59
나. 질 지표의 분류 ------------------------------------ 61
3. AHRQ의 프로그램 ------------------------------------ 63
가. 포괄적 단위기반 안전 프로그램(Comprehensive Unit-based Safety Program, CUSP) ------------------------------------ 63
나. 보건의료공급자 및 시스템에 대한 소비자 평가(Recommended Consumer Assessment of Healthcare Providers and Systems, CAHPS) ------------------------------------ 63
다. 의료 관련 감염(Healthcare Associated Infections, HAI) ------------------------------------ 64
라. 국가 보건의료 질 및 불균형 보고서(National Healthcare Quality and Disparities Reports, NHQR/DR Reports) ------------------------------------ 64
마. 너싱홈 안전 프로그램(Nursing Home Safety Program) ------------------------------------ 65
바. 환자안전조직 프로그램(Patients Safety Organization Program, PSO) ------------------------------------ 65
사. 아동 질 측정 프로그램(Pediatric Quality Measures Program, PQMP) ------------------------------------ 65
4. 국가질포럼 (National Quality Forum, NQF) ------------------------------------ 68

제5장 결론 및 제언 ------------------------------------ 71

참고문헌 ------------------------------------ 79
Abstract ------------------------------------ 99
김정림. (202011). 의료 질 평가 사례 연구 -미국을 중심으로-.
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