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지속가능한 보건의료체계를 위한 지불제도 연구: 묶음지불제 중심으로

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Type
Research report
Author(s)
김지애권순탁장준최윤정박치수문선현
Issued Date
2024-01
Keyword
보건의료지속가능성묶음지불제대안적 지불제healthcare systempaymentsbundled paymentsustainability
Abstract
Korea is undergoing rapid aging, approaching the threshold of becoming an super-aged society by 2025. This demographic shift profoundly impacts the healthcare sector, leading to increased utilization of healthcare services by the aging population and subsequently rising healthcare costs. Additionally, the prevalence of multiple chronic conditions requiring diverse healthcare services is on the rise. This necessitates healthcare system approaches that prioritize people-centered health outcomes and cost-effectiveness. In response to these challenges, various alternative payment models are being explored to address the limitations of traditional payment systems and transition towards a new paradigm of value-based healthcare.
One form of alternative payment models is bundled payment. This involves grouping a series of services (episodes) based on health conditions or the interconnectedness of intervention processes, with the goal of paying costs. Bundled payment focuses on promoting collaboration, coordination, quality improvement, and efficiency enhancement as policy objectives.
The research examines the domestic payment system and its limitations, and explores extensively bundled payments in the United States, the Netherlands, and the United Kingdom. It proposes the applicability of bundled payment elements-retrospective reconciliation mechanism with target prices, and presents options for domestic adoption. Drawing insights from payment system reforms in other countries, the study proposes strategies for domestic implementation.
Successfully transitioning from traditional to innovative payment systems is identified as a significant challenge in the healthcare system. Strategies implemented in countries where payment system reforms have been relatively successful reveals key approaches, including legislative-driven reforms, dedicated organizational establishment, progressive implementation, and increased involvement of healthcare providers. The study underscores the importance of shared accountability for health insurance sustainability among payers, healthcare providers, and users, fostering societal support. This shared accountability increases willingness to accept the uncertainty associated with attempting unfamiliar payment systems compared to familiar ones. The study acknowledges the importance of a dedicated organization to lead systematic payment system reform and the need for cohesive efforts and support from the legislative body.
This research contributes by offering specific strategies for adoption of bundled payment in Repulic of Korea and the implementation of payment system reform. It provides practical technical contents for policymakers, healthcare system designers, and researchers aiming to implement bundled payment in Korea. For effective domestic bundled payment application, it is crucial to improve payment accuracy and diagnostic codes should be monitored, with subsequent research on the bundled payment model design and risk adjustment tool development.
Publisher
건강보험심사평가원
URI
https://repository.hira.or.kr/handle/2019.oak/3211
Alternative Title
A Study on Payments for the Sustainable Healthcare System: Focused on Bundled Payments
Table Of Contents
제1장 서론 ·········································································· 3
1. 연구배경 ···························································································· 3
가. 인구와 질환의 변화에 대응하는 합리적 지불제도 ·········································· 3
나. 지불제도의 보건의료체계에 대한 영향과 역할 ··········································· 4
다. 지불제도 다변화를 위한 대안적 지불제도 시도와 확산 ·································· 6
라. 묶음지불제 ······························································································· 7
2. 연구목적 ······························································································ 7
3. 연구내용 ······························································································ 8
4. 연구방법 ······························································································ 8

제2장 국내 지불제도 현황과 한계 ·········································································· 11
1. 국내 지불제도 성과와 한계 ·································································· 11
가. 행위별수가제 ·························································································· 11
나. 7개 질병군 포괄수가제 ············································································ 12
다. 신포괄지불제도 ······················································································· 13
라. 가감지급사업 ·························································································· 15
2. 소결 ·································································································· 16

제3장 해외 대안적 지불제 ·········································································· 19
1. 미국 묶음지불제 ················································································· 19
가. 도입배경 및 발전 연혁 ············································································ 20
나. CMS 묶음지불제 사업 ············································································ 24
다. CMS 묶음지불제 성과 ············································································ 43
라. 묶음지불제 기대효과와 이슈 ··································································· 45
마. 소결 ······································································································ 51
2. 네덜란드 묶음지불제 ············································································· 52
가. 도입배경 ································································································ 52
나. 네덜란드의 묶음지불제 ············································································· 54
3. 영국 통합의료체계와 묶음지불제도 ························································ 56
가. 추진배경 ································································································ 56
나. 운영체계 및 특징 ···················································································· 56
다. 평가 ······································································································ 58
라. 관련 묶음지불제도 ·················································································· 59
마. 소결 ······································································································ 60

제4장 해외 지불제도 개편 사례 ·········································································· 65
1. 미국 ·································································································· 65
가. 법제화와 전담조직(CMS Innovation Center) ··········································· 65
나. 의료계의 참여 ························································································ 82
다. 소결 ······································································································ 86
2. 대만 ·································································································· 87
가. 개요 ······································································································ 87
나. 개편과정 ································································································ 88
다. 조직과 법령 ··························································································· 91
라. 소결 ······································································································ 95

제5장 대안적 지불제도 설계, 평가 및 실행 ·········································································· 99
1. 대안적 지불제도 개발 ·········································································· 99
가. 성공적인 대안적 지불제도를 위한 설계 단계 ················································ 99
나. 대안적 지불제도 구성 요소 ···································································· 102
다. 대안적 지불제도 실행 및 평가 ······························································· 122
2. 의사 초점 대안적 지불 모델 ································································ 126
가. 의료계가 설계하는 대안적 지불제 모델 ···················································· 126

제6장 지속가능한 보건의료체계를 지원하는 지불제 방안 ·········································································· 139
1. 묶음지불제 국내 적용 가능성 탐색 ····················································· 139
가. 묶음지불제 적용 필요성 ········································································· 139
나. 적용 대상 임상 에피소드 ······································································· 140
다. 적용의 용이성 ······················································································· 141
2. 국내 묶음지불제 적용을 위한 주요 방안 ·············································· 141
가. 방향성 ································································································· 141
나. 지불방식 및 적용 대상 ·········································································· 142
다. 묶음지불제 (목표가격 사전 제시, 사후 조정 기전) 적용(안) ······················· 144
3. 묶음지불제도 실행을 위한 고려사항과 전략 ········································· 147
가. 실행을 위한 고려사항 ·············································································· 147
나. 구현을 위한 전략 ···················································································· 149

제7장 결론 ·········································································· 153
1. 결론 ································································································ 153
2. 연구의 중요성 및 후속 연구 ······························································ 156
가. 연구의 중요성 ······················································································· 156
나. 후속 연구 ···························································································· 156

◾ 참고 문헌 ····················································································· 157
◾ 부록 ··························································································· 163
◾ ABSTRACT ················································································ 198
Publisher
건강보험심사평가원
Location
KOR
Citation
김지애. (2024-01). 지속가능한 보건의료체계를 위한 지불제도 연구: 묶음지불제 중심으로.
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