HIRA

치료재료 실거래가 조사 개선방안

  • 39
  • 82
Metadata Downloads
Type
Research report
Author(s)
윤상헌조쌍은신지혜김예슬
Issued Date
2024-02
Keyword
치료재료실거래가 조사건강보험 청구자료Medical deviceActual transaction price investigationHealth Insurance Review & AssessmentHIRA
Abstract
Under the actual transaction price reimbursement system that compensates for the cost of medical device with the actual purchase price of medical institution within the range of the upper limit of the medic device price list, the actual transaction price investigation has been conducted to improve the transparency of the distribution market and to maintain the soundness of insurance finances by adjusting the upper limit with a weighted average price targeting medical institutions and suppliers, recovering unjust claims and taking administrative actions. However, it is necessary to improve because of issues such as representativeness and fairness due to the target of on-site investigations confined to specific items and medical institutions, difficulties in selecting items to be investigated as most items are charged at the upper limit amount, and prolonged procedures for adjusting the upper limit amount.
This study was conducted to prepare an plan to improve the efficiency of the actual transaction price investigation. The current status and issues were identified, and the system of domestic and foreign drugs and medical devices were compared and considered to suggest way to improve the investigation. We reviewed literature such as related laws, guidelines, and previous studies, empirically analyzed health insurance claim data, medical device purchase history report data, and supply history report data, and conducted simulations to prepare improvement plans. Also opinions were collected from experts and stakeholders in the field.
As a result of the study, we suggested to convert actual transaction price investigation method based on health insurance claim data. The weighted average price(WAP) for each items in medical device price list is calculated by every 2 years, and items with WAPs of 90% or less of the upper price limit are adjusted to the WAP, but the rates do not exceed 20%.
It is meaningful in that this study not only presented systematically and specifically policy goals and directions, action plans, and long/short-term implementation plans for improving the actual transaction price investigation of medical device through literature review, expert consultation, and empirical data analysis, but also prepared an amendment to the notification accordingly.
Publisher
건강보험심사평가원
URI
https://repository.hira.or.kr/handle/2019.oak/3235
Alternative Title
A Study on Improvement of Medical Device Actual Transaction Price Investigation
Table Of Contents
제1장 서론 ································································· 1
1. 연구 배경 ······························································································ 1
2. 연구 목적 ······························································································ 2
3. 연구 내용 및 방법 ·················································································· 3
가. 연구 내용 ·································································································· 3
나. 연구 방법 ·································································································· 3

제2장 치료재료 실거래가 조사 현황 ································································· 7
1. 치료재료 개요 ························································································ 7
가. 치료재료의 정의와 특성 ·············································································· 7
나. 치료재료의 비용 보상과 분류체계 ································································· 8
다. 치료재료의 유통 현황 ··············································································· 10
2. 치료재료 관리체계 ················································································ 12
가. 치료재료 요양급여 등재 및 가격 결정 ························································ 12
나. 치료재료 사후관리 제도 ············································································· 17
다. 치료재료 구입내역 신고 및 요양급여비용 청구 ············································· 21
라. 치료재료 공급내역 보고 ············································································· 23
3. 치료재료 실거래가 조사 현황 ································································· 26
가. 치료재료 실거래가 조사 개요 ····································································· 26
나. 치료재료 실거래가 조사 현황 ····································································· 31
4. 실증적 자료 분석 ················································································· 35
가. 치료재료 실거래가 청구현황 ······································································· 36
나. 치료재료 상한금액과 실거래가 청구금액 차이 ·············································· 57
다. 치료재료 구입내역 신고자료 분석 ······························································· 82
라. 치료재료 공급내역 보고자료 분석 ······························································· 87
마. 소결 ········································································································ 94

제3장 국내·외 사례 고찰 ································································· 101
1. 국내 약제 실거래가 조사 ····································································· 101
가. 의약품 상환제도 및 가격정책 ··································································· 101
나. 약제 상한금액 산정 ················································································· 103
다. 약제 실거래가 조사에 따른 상한금액 조정 ················································· 104
2. 일본 ·································································································· 108
가. 치료재료 ································································································ 108
나. 의약품 ··································································································· 116
3. 대만 ·································································································· 120
가. 치료재료 ································································································ 120
나. 의약품 ··································································································· 124
4. 프랑스 ······························································································· 128
가. 치료재료 ································································································ 128
나. 의약품 ··································································································· 131
5. 호주 ·································································································· 133
가. 치료재료 ································································································ 133
나. 의약품 ··································································································· 135
6. 소결 ·································································································· 138

제4장 치료재료 실거래가 조사 개선방안 ································································· 143
1. 치료재료 실거래가 조사의 문제점 ························································· 143
가. 선행연구 및 정책동향 ·············································································· 143
나. 이해관계자 의견수렴 결과 ········································································ 146
2. 시뮬레이션 ························································································· 150
가. 시뮬레이션 방법 ····················································································· 150
나. 시뮬레이션 결과 ····················································································· 151
3. 치료재료 실거래가 조사 개선방안 ························································· 163
가. 주요 정책 목표 및 추진 방향 ·································································· 163
나. 세부 추진계획 ························································································ 164
4. 관련 고시 개정(안) ············································································· 170
가. 조사 방식 개선 관련 ··············································································· 170
나. 업무 효율성 제고 – 절차 간소화 ······························································ 175

제5장 결론 및 고찰 ································································· 179
1. 결론 ································································································ 179
2. 고찰 ·································································································· 181

◾ 참고 문헌 ························································································· 184
◾ ABSTRACT ······················································································ 189
Publisher
건강보험심사평가원
Location
KOR
Citation
윤상헌. (2024-02). 치료재료 실거래가 조사 개선방안.
Appears in Collections:
HIRA 연구 > 1. 자체연구
Authorize & License
  • Authorize공개
Files in This Item:

열람하신 정보에 대해 만족하십니까?

Comment

Items in Repository are protected by copyright, with all rights reserved, unless otherwise indicated.