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실거래가 약가인하제도 효과평가를 통한 종합적 개선방안 마련 연구

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Type
Research report
Author(s)
김진현권혜영이태진최하영박은하
Issued Date
2022-02
Publisher
건강보험심사평가원
URI
https://repository.hira.or.kr/handle/2019.oak/3101
Table Of Contents
요약 ···························································································· ⅰ

제1장 서론 1
1. 연구 배경 ······························································································ 3
가. 실거래가 약가인하제도 ················································································ 3
나. 처방·조제 장려급 지급제도(2014) ································································· 4
2. 연구 목적 ······························································································ 5
3. 연구 내용 및 방법 ·················································································· 6
가. 연구 내용 ·································································································· 6
나. 연구 방법 ·································································································· 8

제2장 의약품 상환제와 약가결정 9
1. 약품비 상환제도 ··················································································· 11
가. 제3자 지불방식 ························································································ 11
나. 고시가 상환제도 ······················································································· 12
다. 실거래가 상환제도 ···················································································· 13
2. 약가상환가격(상한가)의 결정 ·································································· 14
3. 약가사후관리제도(re-pricing) ································································ 16
가. 실거래가 약가인하제도(repricing based on actual transaction price) ········ 16
나. 사용량-약가연동제 ···················································································· 18
다. 특허만료 시 약가인하 ··············································································· 18
라. 부당이익으로 인한 급여정지 및 제외 ·························································· 18
마. 급여범위 확대 시 사전인하 ········································································ 19
바. 처방·조제 약품비 절감 장려금 ···································································· 19

제3장 외국의 실거래가 약가인하제도 21
1. 일본 ···································································································· 23
가. 지불보상제도 ···························································································· 23
나. 의약품 상환제도: 고시가 상환제 ································································· 24
다. 실거래가 약가인하제도 ·············································································· 24
라. 제도의 효과 ····························································································· 25
2. 대만 ···································································································· 28
가. 지불보상제도 ···························································································· 28
나. 의약품 상환제도: 고시가 상환제 ································································· 28
다. 실거래가 약가 조정제도(Drug price adjustment scheme) ························· 28
라. 제도의 효과 ····························································································· 37
3. 호주 ···································································································· 38
가. 지불보상제도 ···························································································· 38
나. 의약품 상환제도: 고시가 상환제 ································································· 38
다. 실거래가에 기반한 상한가 조정 ·································································· 38
라. 제도의 효과 ····························································································· 49
4. 영국 ···································································································· 50
가. 지불보상제도 ···························································································· 50
나. 의약품 상환제도: 고시가 상환제 ································································· 50
다. 의약품 상환가격 고시 ··············································································· 50
라. 약국의 수입구조 ······················································································· 53
마. 상환가격의 결정 ······················································································· 54
5. 외국제도의 시사점 ················································································ 58

제4장 실거래가 약가인하제도 효과 및 문제점 61
1. 평가 배경 ···························································································· 63
가. 실거래가 약가인하제도의 취지와 목적 ························································· 63
나. 연혁 ········································································································ 63
다. 약가인하 기준 ·························································································· 65
라. 예외조항 ·································································································· 66
마. 실거래가 약가인하제도에 대한 문제제기 ······················································ 67
2. 평가 방법 ···························································································· 74
가. 제도 효과평가의 목적 ··············································································· 74
나. 분석대상 및 자료 ····················································································· 74
3. 실거래가 약가인하제도 효과평가 결과 ····················································· 75
가. 실거래가 분포 현황 ·················································································· 75
나. 약가인하 결과 분석 ·················································································· 86
다. 약가인하 결과 분석 : 품목별 인하율 ·························································· 89
라. 저가구매인센티브와 실거래가 약가인하제도 ·················································· 92
마. 재정절감 현황 ·························································································· 96
4. 시뮬레이션을 통한 재정절감 추정 ························································· 103
가. 인하율 제외구간 도입 ·············································································· 103
나. 국공립병원 등 제외대상 포함 ··································································· 105
다. 성분별 가중평균가 적용 ··········································································· 105
5. 전문가 자문 결과 ··············································································· 107
가. 산업계 ··································································································· 107
나. 학계 ······································································································ 109
다. 소비자단체 ····························································································· 111

제5장 제도의 개선방안 113
1. 들어가며 ···························································································· 115
2. 현행 제도의 개선방안 : 단기적 개선방안 ·············································· 117
가. 10% 인하율 상한 제한 폐지 ··································································· 117
나. 국공립병원의 저가구매가격을 약가인하에 반영 ··········································· 117
다. 이해관계자별 영향분석 ············································································ 118
3. 현행 제도의 개선방안 : 중기적 개선방안 ·············································· 119
가. 실거래가격의 파악 ·················································································· 119
나. 허위보고 시 강력한 처벌 ········································································· 119
다. 재정절감의 실현 ····················································································· 120
라. 저가구매의 촉진 ····················································································· 121
마. 이해관계자별 영향분석 ············································································ 125
4. 장기적 개선방안 : 고시가 상환제로의 전환 ··········································· 126
가. 실구매가와 상한금액의 차액은 요양기관의 합법적 이윤으로 간주 ················· 127
나. 실거래가에 기반한 상한금액의 인하 ·························································· 127
다. 조제료 등 약사 수가구조의 변경 ······························································ 128
라. 외래약품비에 대한 약품비 절감효과의 극대화 ············································ 128
마. 이해관계자별 영향분석 ············································································ 129

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건강보험심사평가원
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김진현. (2022-02). 실거래가 약가인하제도 효과평가를 통한 종합적 개선방안 마련 연구.
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