HIRA

비용기반 포괄수가 조정방안

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Type
Research report
Author(s)
박은철장성인장석용김승훈김현규주재홍박유신정윤화윤나영장예슬장윤서Nerobkova NataliyaOyuntuya Shinetsetseg
Issued Date
2022-12
Publisher
건강보험심사평가원
URI
https://repository.hira.or.kr/handle/2019.oak/3099
Table Of Contents
요약 ···························································································· ⅰ

제1장 서론 1
1. 연구배경 및 목적 ····················································································· 2
가. 연구배경 ······································································································ 2
나. 연구목적 ······································································································ 8
2. 연구내용 및 방법 ····················································································· 8
가. 연구의 틀 ···································································································· 8
나. 연구 내용 ···································································································· 9
다. 연구 방법 ·································································································· 12

제2장 국내 및 국외 포괄수가 고찰 및 문헌검토 17
1. 국내 포괄수가 ························································································ 18
가. 비용(원가) 기반의 포괄수가 산출 방식 ·························································· 18
나. 비용(원가) 기반 포괄수가 조정방안 검토 ······················································· 20
다. 현행 포괄수가 산출 시 사용된 자료원 검토 ··················································· 23
라. 비용(원가) 기반 포괄수가 개편 이후 별도보상 적용 ········································ 24
2. 국외 포괄수가 현황 ················································································ 25
가. 미국 ·········································································································· 25
나. 독일 ·········································································································· 30

제3장 포괄수가 산출자료의 적정성 검토 및 원가보전율 산출 35
1. 원가자료 검토 ························································································ 36
가. 의료기관 비용자료 ······················································································ 36
2. 진료내역자료 수집 결과 ·········································································· 47
가. 원가보전율 산출 ························································································· 47
나. 공공・민간별, 지역별 및 종별 원가보전율 비교 ··············································· 51
다. 비용자료 적정성 검토 ·················································································· 60

제4장 포괄수가 산출방식 63
1. 중증도 0수가 결정 ················································································· 64
가. 진료내역 원가추정 방식-기존방식 ································································· 64
나. 진료내역 원가추정 방식-개선방안 1 ····························································· 66
다. 진료내역 원가추정 방식-개선방안 2 ····························································· 73
라. 진료내역 원가추정 방식-개선방안 3 ····························································· 80
마. 중증도 0 기준수가 결정 ·············································································· 89
2. 중증도 1-3 수가 결정 ············································································ 95

제5장 진료효율화 관련 대조정 방안 101
1. 진료효율화에 대한 적정보상 관련 적용방안 ············································· 102
가. 진료효율화 기준 ······················································································· 102
나. 진료효율화 평가기준 산출과정 ···································································· 104
2. 진료효율화에 따른 적정보상 및 시뮬레이션 ············································· 107
가. 진료효율화에 따른 적정보상 적용 시뮬레이션 ·············································· 107

제6장 연차별 조정 방안 125
1. 연차별 수가조정 관련 적용방안 ······························································ 126
가. 의료경제지수(MEI, Medical Economic Index) 적용 ··································· 126
2. 연차별 수가조정 시뮬레이션 ·································································· 129
가. MEI 산출안 ····························································································· 129
나. MEI 적용 수가 시뮬레이션 ········································································ 134

제7장 연구 조정모델 반영을 위한 운영방식 고찰 및 제언 135
1. 행위별 수가제와 독립된 포괄수가 운영을 위한 방향 ································· 136
가. 현행 포괄수가제 근거법령 ·········································································· 136
나. 현행 비용(원가) 기반 포괄수가제와 관련된 법령의 개선점 ····························· 139
다. 환산지수를 사용하여 포괄수가 조정기전을 유지할 경우 개선방향 ··················· 139
라. 환산지수 외 기전(MEI 등)을 통해 포괄수가를 조정할 경우 개선방향 ············· 140
2. 수가조정 업무 프로세스 ········································································ 143
3. 별도보상 운영방안 관련 사항 ································································· 144
가. 별도보상의 기준에 관한 제언 ····································································· 144
나. 별도보상 운영방안 검토 ············································································· 145

제8장 결론 147
1. 종합 및 제언 ····················································································· 148

부록 ······························································································ 155
참고 문헌 ······················································································ 170
Publisher
건강보험심사평가원
Location
KOR
Citation
박은철. (2022-12). 비용기반 포괄수가 조정방안.
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