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최신 입원환자분류체계를 반영한 전문병원 지정기준 개선 연구

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Type
Research report
Author(s)
박영택장준권순탁최윤정문경준
Issued Date
2024-01
Keyword
전문병원전문병원지정제도입원환자분류체계Specialized hospitalsSpecialty hospitalsSpeciality care
Abstract
Background: Since 2011, the Korean government has been implementing a program for the designation of specialized hospitals (SHs). Hospitals can earn this designation following a successful application and subsequent evaluation. One of the requirements for this designation is the volume of care, which is determined by the total length of stay (LOS) of patients receiving specialty care (PSC). This is also measured using the Korean Diagnosis Related Group (KDRG) code. Currently, the KDRG version (“v”) 3.5 is being used for the designation process, even though the most recent version is v4.4.
Objective: The aim of this study was to examine changes in the volume of care at SHs and general hospitals (GHs), as well as the removal of certain hospitals from the existing SH list when updating KDRG from v3.5 to v4.4. Additionally, this study aimed to propose several policy implications for SHs in light of the update. To achieve these objectives, we analyzed health insurance claim data for the year 2022 and the mapping table between KDRG v3.5 and v4.4.
Results: As of January 2023, there were a total of 113 SHs. An analysis of 94 SHs and 1,907 GHs, excluding oriental medicine hospitals, revealed that the total LOS for PSC was 321,206 days. The average LOS for all patients in SHs was shorter than that of GHs (6.69 versus 9.57 days). However, when only PSC was analyzed, the average LOS in SHs was longer than in GHs (9.0 versus 8.4 days). Significant changes in LOS among hospitals were observed when the KDRG was updated from v3.5 to v4.4. Regarding the requirement that the LOS of hospitals applying for SH status should be within the 30th percentile in the order of the sum of LOS of PSC, the application eligibility change of all hospitals for SHs is as follows. The number of hospitals losing SH application eligibility decreased most significantly in the neurology specialty, at 162 (34.1%), followed by otolaryngology at 52 (18.6%), and spine diseases at 69 (18.1%). This loss of eligibility was associated with the code segmentation and introduction of new codes in KDRG v4.4. Hospitals that lost eligibility were more likely to provide medical care not covered by these codes. When the KDRG was updated from v3.5 to v4.4, two SHs fell out of the designation criteria among the current 113 SHs. The segmentation of KDRG codes, the creation of new classification codes, and other factors influenced this change. An analysis of the 1:1 mapping table between the two versions revealed that the table for KDRG v4.4 has 1,122 unique and 29 missing codes, totaling 1,151 codes after excluding 6 patient classification error codes. The analysis also showed that the number of codes with different code compositions (or letters), but the same name (meaning) was 707 cases (61.4%), and the number of codes with exactly the same code and meaning with 1:1 mapping was 101 cases (8.8%). This study suggests two policy implications from the standpoint of institutions and the managerial efficiency of SHs. For the former, it is necessary to standardize different KDRG versions with consistent comparability, establish perfect mapping master files between different versions, deregulate the requirement of SHs in terms of volume of care, and introduce a healthcare cost index as a requirement for SHs, which could replace the volume of care for PSC. For the latter, it is necessary to add functions that produce statistics on SHs within the Online Analytical Processing (OLAP) System and construct a “Specialized Hospital Management Information System (SHIS)” on the internal network of the Health Insurance Review and Assessment Service (HIRA) for managerial support for SHs.
Discussion: The current study reveals significant changes in the volume of care for PSC across various hospitals upon the application of the latest KDRG v4.4. However, this application only impacted two existing SHs. The current KDRG exhibits little consistency in terms of code composition, meanings, and the mapping table between versions. Therefore, it is necessary to establish a standardized code scheme for KDRG, create a comprehensive mapping table for each version, and construct the SHIS within HIRA’s internal network for managing SHs.
Publisher
건강보험심사평가원
URI
https://repository.hira.or.kr/handle/2019.oak/3213
Alternative Title
A research study on improving the designation guideline of specialized hospitals reflecting the most up-to-date inpatient classification system
Table Of Contents
제1장 서론 ············································································· 3
1. 연구배경 ······························································································ 3
2. 연구목적 ······························································································ 5
3. 연구내용 및 방법 ·················································································· 5
가. 연구내용 및 수행체계 ················································································ 5
나. 연구방법 ·································································································· 7
다. 데이터 분석 ····························································································· 8

제2장 전문병원지정제도와 입원환자분류체계 ············································································· 13
1. 전문병원지정제도 ·················································································· 13
가. 전문병원의 정의 ····················································································· 13
나. 전문병원 관련 제반 규정 ········································································· 14
다. 전문병원의 세부 지정기준 ········································································ 17
2. 입원환자분류체계 ·················································································· 18
가. 입원환자분류체계 개요 ·············································································· 18
나. 최근 입원환자분류체계의 개정 ···································································· 21
다. 입원환자분류체계(KDRG) v4.x의 주요 개정사항 ·········································· 22

제3장 전문병원 지정 및 운영 현황 ············································································· 29
1. 전문병원 지정 현황 ············································································· 29
가. 최근 전문병원 지정 현황 ······································································· 29
나. 세부 분야별 전문병원 수 ········································································· 30
다. 지역별 세부 현황 ···················································································· 31

2. 전문병원 운영 현황 분석 ····································································· 34
가. 분석대상 의료기관 일반 현황 ··································································· 34
나. 전문병원의 전체 환자 입원건수, 입원일수, 평균재원일수 분석 ····················· 35
다. 전문병원의 전문질환자 입원건수, 입원일수, 평균재원일수 분석 ···················· 38
라. 전문병원의 전체 환자 중 전문질환 입원건수, 입원일수, 평균재원일수 분석 ··· 42
3. 전문병원 지정해제 병원의 진료실적 분석 ·············································· 43
가. 분석대상병원 일반 현황 ········································································· 43
나. 전체질환자 진료실적 분석 ········································································ 44
다. 전문질환자 진료실적 분석 ······································································ 46
라. 전문질환 입원건수, 총재원일수, 평균재원일수 비교분석 ······························· 48

제4장 최신 입원환자분류체계 적용 시 전문질환 진료량 변화 ············································································· 52
1. 전문질환 진료량 변화 분석개요 ···························································· 52
2. 분석방법 및 대안 설정 ········································································ 53
가. 분석대상 추출 범위 및 기준 ···································································· 53
나. 질병군 최신화 전후 진료량 변화 분석방법 ················································· 53
3. 최신 입원환자분류체계 적용 후 진료량충족기관 변화 ······························ 55
가. 질병군 최신화 전후 전체 진료량충족기관 변화 ··········································· 55
나. 순위 탈락 10% 이상 질환‧진료과 상세 분석 ··········································· 56
다. 진료량 변화요인 상세 분석 ······································································ 61
라. 최신 입원환자분류체계 적용 시 기존 전문병원의 변화 ································ 74
마. 소결: KDRG v4.4 적용 가능성 ······························································· 75
4. 입원환자분류체계 v3.5와 v4.4의 매핑코드 변화 분석 ····························· 76
가. 최신 입원환자분류체계 v4.4 현황 ····························································· 76
나. 입원환자분류체계 버전 변화에 따른 코드 변화 ··········································· 76
다. 입원환자분류체계 v3.5와 v4.4의 중복코드 ················································ 78
라. 입원환자분류체계 매핑코드 분석에 대한 소결 ············································· 78

제5장 전문병원 지정기준 개선방안 ············································································· 83
1. 제도적 측면 ······················································································· 83
가. 입원환자분류체계 표준화 및 버전 간 매핑체계 구축 ··································· 83
나. 진료량 관련 전문병원지정기준 완화 ·························································· 84
다. 전문병원지정기준에 고가도 반영 ······························································· 84
2. 관리적 측면 ························································································· 85
가. DW시스템을 통한 지원-OLAP에 전문병원 관련 데이터 추출 기능추가 ·········· 85
나. 내부망에 ‘전문병원지정관리시스템’ 메뉴 운영 ·············································· 87
3. 연구의 한계점과 제도개선에 따른 기대효과 ············································· 91

제6장 정책제언 및 결론 ············································································· 95
1. 연구결과 요약 ···················································································· 95
가. 입원환자분류체계 최신화에 따른 진료량 변화 ············································· 95
나. 입원환자분류체계에 따른 기존 전문병원 지정 변화 ····································· 95
다. 입원환자분류체계 버전별 코드 연계 ·························································· 96
2. 제도개선 정책제언 ·············································································· 96
가. 제도적 측면 ··························································································· 96
나. 관리적 측면 ··························································································· 97
다. 연구의 한계점과 제도개선에 따른 기대효과 ················································ 97
3. 결론 ···································································································· 97

◾ 참고문헌 ························································································· 99
◾ 부록 ····························································································· 100
◾ 국문초록 ······················································································· 110
◾ ABSTRACT ················································································· 113
Publisher
건강보험심사평가원
Location
KOR
Citation
박영택. (2024-01). 최신 입원환자분류체계를 반영한 전문병원 지정기준 개선 연구.
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