치료재료 실거래가 조사 개선방안

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.