건강보험청구자료(2016-2022년)를 활용한 일개 지역 진료의뢰 및 회송 청구현황

Abstract

Background: In Korea, the roles of medical institutions are not differentiated. As a result, the proportion of outpatient medical expenses at clinics mainly targeting outpatients decreased by about 9%p from 69.0% in 2006 to 60.3% in 2021, while the proportion of outpatient expenses at tertiary hospitals increased by about 4.5%p from 11.5% in 2006 to 16.0% in 2021. The government has operated a pilot referral and transfer project to improve the medical delivery system. This study aimed to analyze the current status of a pilot project for a referral and transfer system within the community. Methods: This study used data from the National Health Insurance Claims from 2016 to 2022, which included patient information (sex, age, disability, income, and Charlson comorbidity index), medical information (type of medical institution and main diagnosis category), and type of referral and transfer. Results: The number of referral and transfer claims in the region has continued to increase, reaching a total of 296,824. Patients referred for treatment consisted of those aged over 60 years (48.1%), those able to sufficiently cover their medical expenses (42.5%), those without disabilities (90.9%), or those with low disease severity (72.5%). Tertiary and general hospitals had high rates of patients with severe diseases, such as neoplasms (17.2%) or circulatory system diseases (12.6%), returning to local hospitals. Despite the moderate number of referral claims, they have continued to increase yearly, and the methods used to obtain patients’ medical information are also changing. Conclusion: Although transfers to tertiary general hospitals continued to be active, a large gap exists among medical institutions due to the poorly established medical delivery system. Thus, to increase the efficiency of the medical delivery system, wide implementation of various methods is needed to promote referral and transfer.